A PILOT STUDY OF THE HOME APPLICATION OF TRANSCUTANEOUS NEUROMODULATION IN CHILDREN WITH URGENCY OR URGE INCONTINENCE

Third-Line Therapeutic Interventions for Non-Neurogenic Bladder Dysfunction in Children

PURPOSE OF REVIEW

The aim of this article is to review considerations and efficacy of third-line treatments for pediatric non-neurogenic bladder dysfunction, including Botulinum toxin A (BoTNA), Posterior Tibial Nerve Stimulation (PTNS), and Sacral Neuromodulation (SNM).

RECENT FINDINGS

Federal Drug Administration approval for use of beta-3-agonists in overactive detrusor activity in pediatric patients may provide an additional step prior to third-line therapies. New long-term data on pediatric SNM efficacy, complications, and revision rates will provide valuable information for counseling families. BoTNA offers a safe and efficacious treatment to decrease detrusor contractility and improve bladder capacity but is limited by the half-life of BoNTA agent. Percutaneous or transcutaneous PTNS offers improved voided volumes or cure in some patients but is time-intensive. SNM can be utilized in a variety of LUTD pathology with high success rate and cure but should consider cumulative anesthetic and fluoroscopic exposures for battery replacements and re-positioning for patient growth.

Immediate and continued results of parasacral transcutaneous electrical nerve stimulation in paediatric patients with overactive bladders

INTRODUCTION

Among the conditions underlying childhood daytime incontinence the most frequent is overactive bladder (OAB). Parasacral transcutaneous electrical nerve stimulation (parasacral TENS) is a promising therapy for OAB treatment in children; however, there is no standard treatment protocol.

OBJECTIVE

To evaluate the immediate and continued effects of parasacral TENS monotherapy in children with OAB.

STUDY DESIGN

57 children at mean age 10.8 years diagnosed with OAB at a single centre were prospectively enrolled from 2013 to 2018. The inclusion criterion was typical OAB symptoms. The treatment results were evaluated based on objective measurements from bladder diaries, 48 h frequency/volume (48 h F/V) charts, and uroflowmetry. The parasacral TENS treatment lasted for 4 months, twice daily, with 1 h sessions. Results were evaluated at three time points: 2 months of therapy, 4 months (end of active therapy), and 10 months (6 months after cessation of therapy).

RESULTS

After 4 months of parasacral TENS treatment, the number of days with daytime incontinence decreased from 7.23 to 3.94/14 days (p < 0.05), nocturnal enuresis decreased from 6.81 to 3.77/14 days (p < 0.05), and urgency episodes from 7.36 to 3.58 in 14 days (p < 0.05). Treatment effects remained stable 6 months after therapy cessation regarding days with daytime incontinence (from 3.94 [immediately after treatment] to 3.28 in 14 days [6 months after treatment cessation]), nocturnal enuresis (from 3.77 to 2.91 in 14 days), and urgency episodes (from 3.58 to 2.12 in 14 days) (p < 0.05). Complete response after 6 months of therapy was observed in 32% of patients with daytime incontinence, 35% with nocturnal enuresis, and 50% with urgency episodes.

DISCUSSION

A recent systematic review of parasacral TENS in children with OAB included only two studies with a follow up of 6 months or longer after treatment cessation; therefore, little is known about the continued effects of parasacral TENS. High rates of complete symptom remission were reported in studies where only subjective symptoms were evaluated. Results of our study reveal that the positive effect of treatment persist. The strengths of the present study include its prospective design, large sample size, and uniform standard urotherapy performed prior to TENS.

CONCLUSIONS

The use of parasacral TENS in children with OAB is effective and results in a significant reduction in daytime incontinence, nocturnal enuresis, and urgency episodes. A longer treatment duration of 4 months leads to more improvement and the effects remain stable 6 months after treatment cessation.

At-home use of parasacral transcutaneous electrical nerve stimulation for pediatric voiding dysfunction: a randomized controlled trial to assess its safety and feasibility

Introduction

Treating pediatric voiding dysfunction involves behavioral changes that require significant time or medications that are often avoided or discontinued due to side effects. Using parasacral transcutaneous electrical nerve stimulation (PTENS) has shown to have reasonable efficacy, but the safety and feasibility of its off-label use for pediatric voiding dysfunction are not well-established. Concerns have also been raised over treatment adherence. In-home therapy might improve adherence compared with office-based therapy; however, no studies have evaluated in-home feasibility to date. This study aims to assess the safety and feasibility of off-label use of PTENS for pediatric voiding dysfunction.

Materials and methods

A single-institution prospective, randomized controlled study was conducted from March 2019 to March 2020. Participants aged 6-18 years diagnosed with voiding dysfunction, overactive bladder, or urinary incontinence were eligible for the study. Those with known neurologic disorders, implanted electrical devices, anatomic lower urinary tract abnormality, and recurrent urinary tract infections and those taking bladder medications were excluded. Children with primary monosymptomatic nocturnal enuresis were also excluded due to previous work suggesting a lack of efficacy. Participants were randomly assigned to receive 12 weeks of urotherapy alone (control) or urotherapy plus at-home PTENS treatment. Families were contacted weekly to assess for adverse events (AEs) and treatment adherence. The primary and secondary outcomes were safety, defined as the absence of AEs and treatment adherence, respectively.

Results

A total of 30 eligible participants were divided into two groups, with 15 participants in each arm. The median age was 9.4 years (interquartile range: 7.7-10.6). In total, 60% were male. Baseline demographics and urotherapy compliance were similar between the two groups. With PTENS use, two AEs were reported, including mild pruritus at the pad site and discomfort when removing pads, while no AEs were noted in the control group. In total, 60% of patients completed three 30-min sessions per week, and all participants were able to complete treatment sessions for at least 10 weeks, involving 30 min of PTENS treatment each time.

Conclusion

This randomized controlled study confirms that at-home use of PTENS is feasible with reasonable treatment adherence and minimal AEs. Future collaborative, multi-institutional studies may better determine the efficacy of this treatment modality.

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.

Non-retentive faecal incontinence in children: Conventional therapy alone or combined electrical stimulation

AIMS

To compare the effects of functional electrical stimulation (FES) with conventional therapy and conventional therapy alone on improvement of faecal incontinence (FI) symptoms in a number of children with functional non-retentive FI.

METHODS

Data of 28 children with FI were accepted for this retrospective study. The case group (n = 14) underwent FES + conventional therapy and the control group (n = 14) received conventional therapy only. Data of children with faecal retention, inflammatory, anatomic, metabolic and neurological disorders were excluded. Children were assessed with a paediatric FI score questionnaire, and a bowel habit diary both before treatment sessions, after they ended, and after 6 months. A FI quality of life questionnaire was completed before and after treatment for all children.

RESULTS

Full response to the treatment (100% reduction in FI episodes) was significantly observed in 8/14 (57.1%) of children in the case group compared to 2/14 (14.2%) of children in the control group after the ending of treatment sessions (P = 0.005). The baseline mean ± SD of FI episodes per week was 3.7 ± 2.1 among both groups which significantly decreased after the ending of treatment sessions in the case group compared to the control group (1.4 ± 2.1 vs 3 ± 2.7; P = 0.05). Mean ± SD of FI score was significantly reduced in the case group compared to the controls after the ending of treatment sessions (3.9 ± 4.5 vs 8 ± 4.7; P = 0.02) and maintained after 6 months (P = 0.05).

CONCLUSIONS

Functional electrical stimulation is a safe, effective, non-invasive, inexpensive, reproducible and easy-to-use modality for treatment of functional non-retentive faecal incintinence in children.

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.

Transcutaneous sacral electrical stimulation versus oxibutynin for the treatment of overactive bladder in children

BACKGROUND

Nowadays there is still no ideal treatment for paediatric overactive bladder. Initial management measures (urotherapy and constipation control), resolve 40% of cases. The second line of treatment in overactive bladder is anticholinergic drugs, above all oxybutynin. Although most patients improve with these therapies, the complete resolution rate is around 30-40%. Sacral transcutaneous electrical nerve stimulation has recently emerged as a new alternative in the management of patients with refractory paediatric overactive bladder. However, only a few studies have been done to compare the effectiveness of this therapy versus conventional drugs.

OBJETIVE

The objective of the present study is to compare, in children with overactive bladder, the efficacy of the sacral transcutaneous electrical nerve stimulation versus oxybutynin therapy.

MATERIALS AND METHODS

We performed a prospective and randomized study of patients with diagnosis of overactive bladder treated with sacral transcutaneous electrical nerve stimulation versus oxybutynin, during the period July 2018-July 2020. Patients refractory to standard urotherapy and constipation management randomly received one of the therapeutic alternatives. Treatment was maintained for 6 months.

RESULTS

86 patients were included in the study: 40 patients received electrotherapy (group 1) and 46 patients received oxybutynin (group 2). Before starting the treatment assigned both groups were comparable related to the voiding symptomatology as well as the severity of the overactive bladder. Sacral transcutaneous electrical nerve stimulation was significantly more effective than oxybutynin, with a higher percentage of complete resolution of symptoms in the management of paediatric overactive bladder.

VOIDING DIARY

All the parameters obtained with the voiding calendar significantly improved in both groups at the end of the treatment. The increase in MaVV was significantly higher in group-1.

DVISS (DYSFUNCTIONAL VOIDING AND INCONTINENCE SCORING SYSTEM)

We observed a progressive decrease in the mean score obtained in the DVISS questionnaire over time in both groups. This decrease was significantly higher in group-1 compared to group-2 (p < 0.005). The mean value obtained in the DVISS questionnaire in group-1 was 6 (interquartile range: 3-9) at the end of the treatment (lower than the diagnostic cut-off point for daytime condition in the DVISS, 8.5). In group-2, the mean value obtained in the DVISS questionnaire was 10 (interquartile range: 8.75-13.25), higher than the cut-off point.

COMPLICATIONS

A greater number of adverse effects was obtained in group-2 (26.1% versus 15%, p < 0.05). Constipation (n: 6, 10.9%), and abdominal pain (n: 2,4.3%) were the most frequent adverse effects in this group. The adverse events reported in group-1 were contact dermatitis (n: 1.2%) and fecal losses [2] or urgency [5].

CONCLUSION

Oxybutynin and sacral transcutaneous electrical nerve stimulation are both effective therapies in the management of paediatric overactive bladder. However, electrotherapy has been shown to be a more effective therapy with a complete clinical resolution rate in a larger number of patients. Furthermore, the rate of adverse effects secondary to electrotherapy is significantly lower than those treated with oxybutynin.

An Examination of the Relationship between Urinary Neurotrophin Concentrations and Transcutaneous Electrical Nerve Stimulation (TENS) Used in Pediatric Overactive Bladder Therapy

This article aims to explore changes in urinary concentrations of selected neurotrophins in the course of TENS therapy in children with overactive bladder (OAB). A two-group open-label prospective study was conducted. The intervention group comprised 30 children aged between 5 and 12 years old with OAB refractory to conservative therapy. They received 12 weeks of TENS therapy in a home setting. The urinary neurotrophins, NGF, BDNF, NT3, NT4, were measured by ELISA at baseline and at the end of the TENS therapy. Total urinary neurotrophins levels were standardized to mg of creatinine (Cr). We compared the results with the reference group of 30 participants with no symptoms of bladder overactivity. The results revealed that children with OAB both before and after TENS therapy had higher NGF, BDNF, and NT4 concentrations in total and after normalization to Cr than the reference group in contrast to NT3. The response to the therapy expressed as a decrease of urinary neurotrophins after TENS depended on the age and the presenting symptoms. In conclusion, children older than 8 years of age with complaints of daytime incontinence responded better to TENS.

Parasacral transcutaneous electrical nerve stimulation in children with overactive bladder: comparison between sessions administered two and three times weekly

Purpose:

This study compares the results achieved following parasacral TENS administered using two different weekly schedules.

Materials and Methods:

Children of at least four years of age with a diagnosis of pure overactive bladder were included in this randomized clinical trial and treated with parasacral TENS (2 versus 3 sessions per week). All the participants also underwent standard urotherapy.

Results:

Sixteen children were included in the twice-weekly group and eighteen in the three times weekly group. There were no statistically significant differences between the two groups with respect to sex; however, there was a difference in age. There were no significant differences regarding complete resolution of urinary symptoms, with 8 children (50%) in the twice-weekly group and 11 children (61%) in the three times weekly group having their symptoms completely resolved (p=0.73). There was a significant difference in the DVSS score in both groups following TENS treatment compared to baseline (p=0.0001 for both groups), but not between groups. Evaluation of the bladder diary showed no difference between the groups before or after treatment.

Conclusion:

For children with overactive bladder who are unable to undergo parasacral TENS treatment three times weekly, the method can be administered successfully at twice-weekly sessions.

Dysfunctional voiding: update on evaluation and treatment

PURPOSE OF REVIEW

This review will be covering dysfunctional voiding, its diagnosis, and treatment options. This will focus primarily on dysfunctional voiding rather than all lower urinary tract dysfunction and we will focus on some of the newer findings and progress within this disease.

RECENT FINDINGS

Dysfunctional voiding is the inappropriate sphincter and pelvic floor constriction during voiding in an otherwise neurologically normal child. This has a wide spectrum of symptoms and can lead to a number of complications such as chronic kidney disease and poor quality of life if not appropriately addressed. Dysfunctional voiding is diagnosed with a careful examination and history with further imaging including a renal ultrasound and uroflowmetry to confirm the diagnosis. Urotherapy and biofeedback are the first and second-line treatments respectively and lead to significant improvement or cure in the majority of patients. For refractory patients, additional therapy options include use of α-blockers, botulinum injection, and electroneurostimulation, though the majority of the literature surrounding the use of these therapies consists of small studies with heterogenous causes of voiding dysfunction.

SUMMARY

Dysfunctional voiding is a common urologic complaint that has many excellent options for improving the patient's voiding issues and should be considered in patients with voiding dysfunction.

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.

Magnetic resonance image connectivity analysis provides evidence of central nervous system mode of action for parasacral transcutaneous electro neural stimulation - A pilot study

INTRODUCTION

Parasacral transcutaneous electriconeural stimulation (pTENS) is a common treatment modality for patients with overactive bladder (OAB). Its mechanism of effectiveness has yet to be elucidated. Recent studies with fMRI in adults with implanted sacral nerve stimulators impute its effectiveness on changes in the brain involving the anterior cingulate cortex (ACC) and prefrontal cortex (PFC).

AIM

The study set out to evaluate brain connectivity utilizing functional MRI to the outline the mechanism of action of pTENS in the brain.

METHODS

Ten adult volunteers without urinary tract symptoms underwent fMRI. Electrodes were placed on the skin at sacral level (S2) (Experimental Stimulation - pTENS) and on the right scapular region (Sham Stimulation - sTENS). Stimulation was done twice on each site for 6 min at a frequency of 10 Hz and pulse width of 260 μs and intensity determined by the motor threshold. A 6 min resting state fMRI was also done twice as control. Functional connectivity data was acquired during each state (resting, pTENS and sTENS). Standard functional connectivity preprocessing was performed. Seed connectivity was examined to investigate changes in ACC functional connectivity between the stimulations and resting-state conditions. Significance was assessed at p < 0.05 corrected for multiple comparisons.

RESULTS

For all conditions (pTENS, sTENS, and rest), standard patterns of ACC connectivity were detectable with strong connectivity between the ACC and subcortical regions and between the ACC and the frontal lobe. Functional connectivity between ACC seed and the dorsal lateral prefrontal cortex (DLPFC) was significantly increased during pTENS compared to rest. sTENS did not increase connectivity between the ACC seed and DLPFC when compared to rest.

DISCUSSION

Preliminary results indicate that ACC is a major site of activation during pTENS. Increased connectivity between ACC and DLPFC may be a possible mechanism of pTENS effectiveness, which appears to be specific to pTENS compared to sTENS. This study is limited to the small size at this time which prevents further investigation at other sites in the brain.

CONCLUSIONS

The study confirms our original aim which was to define if parasacral TENS actually has a central effect.

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.

Impact of transcutaneous interferential electrical stimulation for management of primary bladder neck dysfunction in children

INTRODUCTION

Several studies have revealed that electrical stimulation is an effective modality for treatment of lower urinary tract (LUT) dysfunction via raising the capacity or compliance of the bladder or maybe by pelvic floor relaxation and reducing detrusor pressure as well.

OBJECTIVE

This study aimed to assess the efficacy of transcutaneous interferential (IF) electrical stimulation on LUT symptoms as well as urine flow parameters in children with primary bladder neck dysfunction (PBND).

STUDY DESIGN

We reviewed the charts of all children with persistent LUT symptoms who underwent IF electrical stimulation between 2010 and 2017. Twenty-three neurologically and anatomically normal children (mean age: 7.7 years, range: 5-13) with LUT symptoms were included in this study. Children had different LUT symptoms such as hesitancy, straining, urinary incontinence and constipation with no sufficient response to medical treatment (α -blocker) for at least 6 months. IF electrical stimulation was performed for 15 sessions, two times per week. All children were symptomatic and had abnormal urine flow pattern with an electromyographic (EMG) lag time of more than 6 s on uroflowmetry with EMG. A voiding chart, uroflowmetry with EMG and kidney and bladder ultrasounds were performed before and after the treatment for all children. Maximum and average urine flow rates, EMG lag time and postvoid residual volume were analyzed. In addition, alpha blocker therapy was continued during IF therapy.

RESULTS

Mean maximum and average urine flow rates improved from 14.1 to 7.6-19.7 ml/s and 9.5 ml/s, respectively, while mean EMG lag time decreased from 11.7 to 5.2 s after the treatment (all P < 0.05). Also postvoid residual volume decreased significantly from 35.6 to 7.6 ml at the end of treatment courses.

DISCUSSION

Pelvic floor EMG lag time, a documented parameter on uroflowmetry with EMG, defined as the time from the start of pelvic floor relaxation during a volitional voiding effort (the first stage of normal voiding) to the start of urine flow. Results showed that IF therapy decreased pelvic floor EMG lag time in children with PBND. In addition, increase in mean maximum and average urine flow rates in our patients indicated that pelvic IF therapy and behavioral modification improved voiding dysfunction in most of the patients and probably decreased bladder neck activity during voiding. Future studies with larger sample size are needed to support this finding.

CONCLUSION

IF therapy appears safe, effective and reproducible in improvement of PBND in children.

Fluids affecting bladder urgency and lower urinary symptoms (FABULUS): methods and protocol for a randomized controlled trial

INTRODUCTION AND HYPOTHESIS

We present the design of a randomized controlled trial, Fluids Affecting Bladder Urgency and Lower Urinary Symptoms (FABULUS), with the purpose of testing the common clinical advice of treating overactive bladder by eliminating potentially irritating beverages (PIBs) that are caffeinated, artificially sweetened, citric, or alcoholic. The primary hypothesis is that women taught to reduce PIBs will show less void frequency compared with a control group instructed in diet/exercise recommendations. Secondary outcomes include change in urgency symptoms and volume per void.

METHODS

We report the methods for FABULUS and discuss how challenges presented in the literature and from a prior proof-of-concept feasibility trial are addressed by strengthening study design, procedures, and instruments. We introduce the concept of standardized automated tutorials for assisting participants in compliance from study start to finish. The tutorials contain a detailed explanation of the study, including tips for complying with the extensive diary requirements, and parallel tutorials to intervention and control groups for consistency in format and time of instructional content. The intervention tutorial on eliminating PIBs places emphasis on maintaining steady fluid intake volume, as fluctuations have been a confounder in prior work.

RESULTS

Study results promise to inform about both the tutorial approach and specific PIB reduction for effectively treating overactive bladder.

CONCLUSIONS

OAB can have a negative impact on quality of life, and current medical treatments carry costs and side-effect risks. If simple lifestyle changes can improve or prevent these bladder symptoms, multiple medical and public health advances could result.

Comparative assessment of efficacy and safety of different treatment for de novo overactive bladder children: A systematic review and network meta-analysis

Objective

To compare these managements focusing on the efficacy and safety to treat overactive bladder (OAB) in children through network meta-analysis (NMA).

Methods

We searched PubMed, Embase, the Cochrane Library Central Register of Controlled Trials (CENTRAL) and the reference lists up to May 1st, 2017. Data from eligible randomized controlled trails (RCT) studies including three different treatment options were extracted. The primary outcome was maximal voiding volume (MVV). We performed pairwise meta-analyses by random effects model and NMA by Bayesian model. We used the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) framework to assess the quality of evidence contributing to each network estimate.

Results

Six RCTs (462 patients) comparing three different interventions fulfilled the inclusion criteria. A low risk of bias was shown for the majority of the study items. The results of NMA showed that compared with antimuscarinic drugs, Parasacral transcutaneous electrical nerve stimulation was associated with significant improvement in the MVV (mean difference [MD] = 58.50, 95% confidential interval [CI]: 45.95–69.52), followed by urotherapy group (MD = 21.03, 95% CI: 11.85–29.97). When it comes to the constipation, antimuscarinic drugs exerted significant benefit than PTENS (odds ratio [OR]: 0.22, 95% CI: 0.01–0.46). No significant difference was found between other treatments.

Conclusion

Compared with antimuscarinic drugs, PTENS was associated with significant better efficacy considering MVV, but more constipation events in de novo OAB children. Antimuscarinic drugs showed remarkably better efficacy considering MVV and comparable safety profile compared with urotherapy. Clinicians should take all known safety and compliance of patients into account when choosing an optimal strategy.

Traditional Biofeedback vs. Pelvic Floor Physical Therapy-Is One Clearly Superior?

PURPOSE OF REVIEW

Pelvic floor physical therapy is a worldwide accepted therapy that has been exclusively used to manage many pelvic floor disorders in adults and children. The aim of this review is to suggest to clinicians an updated understanding of this therapeutic approach in management of children with non-neuropathic voiding dysfunction.

RECENT FINDINGS

Today, pelvic floor muscle training through biofeedback is widely used as a part of a voiding retraining program aiming to help children with voiding dysfunction which is caused by pelvic floor overactivity. Biofeedback on its own, without a pelvic floor training component, is not an effective treatment. Biofeedback is an adjunct to the pelvic floor training. In the current review, we develop the role of pelvic floor physical therapy in management of children with non-neuropathic voiding dysfunction and compare it with biofeedback therapy alone.

Genital nerve stimulation is tolerable and effective for bladder inhibition in sensate individuals with incomplete SCI

BACKGROUND

Neurogenic detrusor overactivity after spinal cord injury (SCI) causes urinary incontinence and reduces bladder capacity. Surface electrical genital nerve stimulation (GNS) acutely inhibits reflex bladder contractions. The stimulation amplitude selected for GNS is typically twice the amplitude that is required to evoke the pudendal-anal reflex. There is concern about the ability of persons with sensation to comfortably tolerate effective levels of GNS. The objective of this work is to determine if persons with incomplete SCI are able to tolerate acute GNS for bladder inhibition.

METHODS

Twenty-four subjects with neurogenic detrusor overactivity, SCI, and pelvic sensation were enrolled in this case series. The setting was the Spinal Cord Injury Service of a Veterans Affairs Medical Center. Primary outcome measures were sensation threshold and tolerable stimulation amplitude; secondary outcome measures were bladder capacity and bladder contraction inhibition.

RESULTS

GNS was tolerable up to 30±16 mA (range 8 mA to ≥60 mA) at amplitudes greater than twice the pudendal-anal (PA) reflex threshold, which was 8±5 mA (range 4 mA to 20 mA). Twelve subjects tolerated GNS at greater than twice the PA, six tolerated 1-1.5 times the PA, and five had no identifiable PA. GNS at tolerable amplitudes inhibited reflexive bladder contractions or increased bladder capacity 135±109 mL (n=23). GNS did not cause autonomic dysreflexia or intolerable spasticity.

CONCLUSIONS

GNS is tolerable at amplitudes that effectively inhibit neurogenic detrusor overactivity in individuals with pelvic sensation. GNS therefore is a tool with potential clinical applications for persons with preserved sensation.

Parasacral transcutaneous electrical neural stimulation (PTENS) once a week for the treatment of overactive bladder in children: A randomized controlled trial

INTRODUCTION

Overactive bladder (OAB) is the most prevalent voiding disorder in childhood, and its main manifestation is urinary urgency. In general, urotherapy and anticholinergics are the first choices of treatment. Parasacral Transcutaneous Electrical Neural Stimulation (PTENS) was introduced as an alternative for the treatment of detrusor overactivity in children, but treatment protocols described to date require several sessions per week or long-lasting sessions, making it difficult for the child to adhere to the treatment. Thus, this study aims to evaluate the effectiveness of PTENS in single weekly sessions in the treatment of OAB in children.

STUDY DESIGN

This prospective, randomized controlled trial included 16 children with OAB. Children were divided into two groups: CG (urotherapy and electrical stimulation placebo) and EG (urotherapy and PTENS). For both groups, therapy was delivered in 20 weekly sessions, of duration 20 min each. Placebo electrical stimulation was done in the scapular area. The children were evaluated prior to treatment (T1), at the end of the 20 sessions (T2), and 60 days after the completion of treatment (T3), with a 3-day voiding diary, visual analogue scale (VAS), Rome III diagnostic criteria, and the Bristol Scale.

RESULTS

The groups were similar in age, gender, and ethnicity. In the initial assessment, all children, in both groups, had urgency and incontinence, 50% in each group had constipation, and enuresis was present in seven children (87.5%) in the EG and six (75%) in the CG. No differences were found between the groups regarding the volumetric measurements made in the voiding diary, urinary frequency and constipation evaluated by the Rome III criteria and the Bristol Scale. Sixty days after treatment, a significant improvement was found in the EG group (p = 0.03) regarding urgency (Table), as well as an increase in dry nights in those presenting with enuresis (p = 0.03). No difference was noted regarding urinary incontinence (Table). At the end of 20 sessions and after 60 days of treatment, those responsible for the children in the EG perceived greater improvement in symptoms measured by the VAS (p = 0.05 and 0.04, respectively).

CONCLUSIONS

Our preliminary results demonstrate that PTENS performed in single weekly sessions is effective in treating the bladder for symptoms of urinary urgency and enuresis, and in the perception of those responsible for the children. Further studies with larger populations are needed to corroborate these results.

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

PURPOSE

We evaluated whether combination therapy with transcutaneous electrical nerve stimulation and oxybutynin results in a superior treatment response compared to either therapy alone in children with urge incontinence.

MATERIALS AND METHODS

In this placebo controlled study 66 children with a mean ± SD age of 7.3 ± 1.6 years who were diagnosed with urge incontinence were randomized to 3 treatment groups. Group 1 consisted of 22 children undergoing transcutaneous electrical nerve stimulation plus active oxybutynin administration. Group 2 included 21 children undergoing active transcutaneous electrical nerve stimulation plus placebo oxybutynin administration. Group 3 consisted of 23 children undergoing active oxybutynin administration plus placebo transcutaneous electrical nerve stimulation. The children received active or placebo transcutaneous electrical nerve stimulation over the sacral S2 to S3 outflow for 2 hours daily in combination with 5 mg active or placebo oxybutynin twice daily. The intervention period was 10 weeks. Primary outcome was number of wet days weekly. Secondary outcomes were severity of incontinence, frequency, maximum voided volume over expected bladder capacity for age, average voided volume over expected bladder capacity for age and visual analogue scale score.

RESULTS

Combination therapy was superior to oxybutynin monotherapy, with an 83% greater chance of treatment response (p = 0.05). Combination therapy was also significantly more effective than transcutaneous electrical nerve stimulation monotherapy regarding reduced number of wet days weekly (mean difference -2.28, CI -4.06 to -0.49), severity of incontinence (-3.11, CI -5.98 to -0.23) and daily voiding frequency (-2.82, CI -4.48 to -1.17).

CONCLUSIONS

Transcutaneous electrical nerve stimulation in combination with oxybutynin for childhood urge incontinence was superior to monotherapy consisting of transcutaneous electrical nerve stimulation or oxybutynin, although the latter only reached borderline statistical significance. Furthermore, transcutaneous electrical nerve stimulation was associated with a decreased risk of oxybutynin induced post-void residual urine greater than 20 ml.

Does Instruction to Eliminate Coffee, Tea, Alcohol, Carbonated, and Artificially Sweetened Beverages Improve Lower Urinary Tract Symptoms?: A Prospective Trial

PURPOSE

Common advice for lower urinary tract symptoms (LUTS) such as frequency, urgency, and related bother includes elimination of potentially irritating beverages (coffee, tea, alcohol, and carbonated and/or artificially sweetened beverages). The purpose of this study was to determine compliance with standardized instruction to eliminate these potentially irritating beverages, whether LUTS improved after instruction, and whether symptoms worsened with partial reintroduction.

DESIGN

The 3-phase fixed sequence design was (1) baseline, (2) eliminate potentially irritating beverages listed above, and (3) reintroduce at 50% of baseline volume, with a washout period between each 3-day phase. We asked participants to maintain total intake volume by swapping in equal amounts of nonpotentially irritating beverages (primarily water).

SUBJECTS AND SETTING

The study sample comprised 30 community-dwelling women recruited through newspaper advertisement.

METHODS

Quantification measures included 3-day voiding diaries and detailed beverage intake, and LUTS questionnaires completed during each phase.

RESULTS

During Phase 2, we found significant reduction in potentially irritating beverages but complete elimination was rare. Despite protocol demands, total beverage intake was not stable; mean (± standard deviation) daily total intake volume dropped by 6.2 ± 14.9 oz (P = .03) during Phase 2. In Phase 3, the volume of total beverage intake returned to baseline, but the intake of potentially irritating beverages also returned to near baseline rather than 50% as requested by protocol. Despite this incomplete adherence to study protocols, women reported reduction in symptoms of urge, inability to delay voiding, and bother during both phases (P ≤ .01). The number of voids per day decreased on average by 1.3 and 0.9 voids during Phases 2 and 3, respectively (P = .002 and P = .035).

CONCLUSIONS

Education to reduce potentially irritating beverages resulted in improvement in LUTS. However, eliminating potentially irritating beverages was difficult to achieve and maintain. Study findings do not allow us to determine whether LUTS improvement was attributable to intake of fewer potentially irritating beverages, reduced intake of all beverages, the effect of self-monitoring, or some combination of these factors.

Electroneurostimulation for the management of bladder bowel dysfunction in childhood

Both non-invasive and invasive electroneurostimulation (ENS) modalities for bladder bowel dysfunction have been studied and reported in children. A summary of the proposed mechanism of actions and the more commonly used and recently reported techniques and outcomes are described. This includes transcutaneous electrical nerve stimulation, functional electrical nerve stimulation, intravesical electrical nerve stimulation, percutaneous tibial nerve stimulation and sacral neuromodulation in conditions including overactive bladder, enuresis, dysfunctional voiding, constipation, combined bladder bowel dysfunction and neuropathic bladder and bowel dysfunction. There is a need for further high quality randomised trials as well as long-term outcomes to establish whether ENS is able to alter the long-term trajectory for an individual child with bladder bowel dysfunction.

No immediate effect on urodynamic parameters during transcutaneous electrical nerve stimulation (TENS) in children with overactive bladder and daytime incontinence-A randomized, double-blind, placebo-controlled study

AIM

To evaluate the immediate effect on natural fill urodynamic parameters and bladder function during transcutaneous electrical nerve stimulation (TENS) in children with overactive bladder (OAB) and daytime urinary incontinence (DUI).

MEETHODS

In this double-blind, placebo-controlled study, 24 children with severe OAB and DUI (mean age 8.5 ± 1.2 years) underwent 48-h natural fill urodynamics. After 24 h of baseline investigation, the children were randomized to either active continuous TENS (n = 12) or placebo TENS (n = 12) over the sacral S2-S3 outflow. The urodynamic recordings were analyzed manually for three different bladder contraction patterns resulting in a void. The number of bladder contractions not leading to a void was also calculated. Maximum voided volume (MVV) and average voided volume (AVV) were identified for both the baseline and the intervention day.

RESULTS

We found that TENS had no immediate objective effect on bladder capacity. The difference (before minus after treatment) in MVV/EBC in the active TENS group = 0.03 ± 0.23 versus placebo TENS group = -0.01 ± 0.10 (P = 0.61). Also, there was no significant difference in the proportion of different bladder contraction types between the two groups. TENS did not significantly influence the number of bladder contractions not leading to a void. Results are presented as mean ± SD.

CONCLUSION

There is no immediate objective effect of TENS on bladder activity assessed by natural fill urodynamics in children with OAB and DUI.

Parasacral transcutaneous electrical stimulation for overactive bladder in children: An assessment per session

OBJECTIVE

Neuromodulation has emerged as an effective therapeutic option for treatment of OAB in children. However, to our knowledge, no study has yet evaluated the results of neuromodulation on a session-by-session basis. The aim of this study was to evaluate the rate of complete response of overactive bladder (OAB) symptoms for each session of transcutaneous electrical stimulation (TENS), in a protocol of 20 sessions of therapy.

METHOD

This is a prospective study of the improvement of LUTS in children with isolated OAB. Included in this study were children over the age of 4 years who complained of urinary urgency, had bell-or tower-shaped uroflowmetry patterns, and post-void residual <10% of expected capacity for their age and/or less than 20 mL. No patient was treated with an anticholinergic. Children were excluded with lower urinary tract symptoms (LUTS) secondary to urinary tract abnormalities. All patients underwent parasacral transcutaneous neurostimulation (TENS). The development of symptoms was observed right before each session using a visual analog scale (VAS) in which 0 means the absence of improvement and 10 represents maximum improvement of symptoms.

RESULTS

We noted a complete resolution of symptoms (urgency, urge incontinence, frequency, and holding maneuvers) in some patients starting after the third session. In the 10th and 20th (last) sessions, 12 (17.4%) and 38 (55.1%) patients reported a complete resolution of symptoms. After complete resolution, 12 (17.4%) patients reported that their symptoms worsened to a minimum level of 40% improvement, but this was temporary and all returned to 100% improvement. Children who showed an improvement level greater than 50% in the fifth treatment session were 4.18 (p = 0.007) times more likely to have success in the last treatment session.

CONCLUSION

We found that a patient can experience complete symptom resolution as quickly as following the third session of TENS. The complete response rate progressively increases with the number of sessions, slowly until the 12th session and more rapidly after that. When symptom improvement of at least 50% is reported in the fifth session, there is a higher chance that the patient will have full resolution of symptoms at the end of treatment.

Overactive bladder in children

Overactive bladder (OAB) is a ubiquitous syndrome that is defined by urinary urgency with, or without urinary incontinence. OAB is observed in all parts of the world, with a prevalence of 5-12% in children (5-10 years of age) and a prevalence of 0.5% in older adolescents (16-18 years of age). Published data indicate that around a third of children with OAB are likely to become adults with similar complaints. Studies in children and in adults with OAB indicate that these individuals are more likely to also have anxiety, depression and attention deficit problems, and that appropriate treatment of these comorbidities can often improve the patient's OAB symptoms. Furthermore, data from twin studies and familial surveys seem to indicate a genetic component of OAB. Pharmacological treatments of OAB in children have improved in the past 5 years, moving beyond anticholinergic agents and including the off-label use of α-blockers, β3-agonists and intravesical botulinum toxin. Use of several different electrical stimulation techniques is also effective, both as first-line treatments, and for patients with treatment-refractory symptoms. Overall the outlook of children with OAB seems to be improving, with a greater understanding of the pathophysiology of this syndrome. Treatment modalities that target the source of the underlying problem, especially in children, are likely to provide the best patient outcomes.

Pathophysiological and Therapeutic Considerations for Non-Neurogenic Lower Urinary Tract Dysfunction in Children

Non-neurogenic lower urinary tract dysfunction (LUTD) in children is very common in clinical practice and is important as an underlying cause of lower urinary tract symptoms, urinary tract infection and vesicoureteral reflux in affected children. LUTD in children is caused by multiple factors and might be related with a delay in functional maturation of the lower urinary tract. Behavioral and psychological problems often co-exist in children with LUTD and bowel dysfunction. Recent findings in functional brain imaging suggest that bladder bowel dysfunction and behavioral and psychiatric disorders in children might share common pathophysiological factors in the brain. Children with suspected LUTD should be evaluated properly by detailed history taking, validated questionnaire on voiding and defecation, voiding and bowel diary, urinalysis, screening ultrasound, uroflowmetry and post-void residual measurement. Invasive urodynamic study such as videourodynamics should be reserved for children in whom standard treatment fails. Initial treatment of non-neurogenic LUTD is standard urotherapy comprising education of the child and family, regular optimal voiding regimens and bowel programs. Pelvic floor muscle awareness, biofeedback and neuromodulation can be used as a supplementary purpose. Antimuscarinics and α-blockers are safely used for overactive bladder and dysfunctional voiding, respectively. For refractory cases, botulinum toxin A injection is a viable treatment option. Prudent use of urotherapy and pharmacotherapy for non-neurogenic LUTD should have a better chance to cure various problems and improve self-esteem and quality of life in affected children.

Transcutaneous Electrical Nerve Stimulation Increases Rectal Activity in Children

OBJECTIVES

Neurostimulation is increasingly used in treating bladder and bowel dysfunction, but its effect on rectal motility is obscure. The aim of the study was to evaluate the acute effect of transcutaneous electrical nerve stimulation (TENS) on rectal motility in children with overactive bladder (OAB).

METHODS

In this double-blind placebo-controlled study in 20 children with OAB (mean age 8.6 ± 1.8 years; 7 girls), 48-hour urodynamic monitoring including rectal manometry was performed. After 24-hours of baseline investigation without stimulation the children were randomised to either active TENS (n = 10) or placebo (n = 10). Surface electrodes were placed over the sacral bone. The exterior of active and placebo stimulators was identical. Starting in the morning, the children received either continuous TENS stimulation or placebo until bedtime. Rectal contractions were de&filig;ned as pressure runs exceeding 5 cm H2O and lasting ≥3 minutes.

RESULTS

At baseline there was no significant difference in proportion of time with rectal contractions in the 2 groups (TENS group median 31% [range 12%-66%] vs placebo group median 31% [range 10%-66%]; P = 0.75); however, on the day of stimulation there was more time with rectal contractions in the group receiving TENS (median 51% [range 25%-78%]) compared with placebo (median 32% [range 4%-68%]; P = 0.02). Also, there was an increase in time with rectal contractions in the TENS group (P = 0.007) but not in the placebo group (P = 0.39). The night after the TENS was disabled, rectal activity in both groups returned to baseline level.

CONCLUSIONS

TENS acutely increases time with rectal contractions in children undergoing urodynamic investigation. The effect disappears when the stimulator is turned off.

Urodynamic outcome of parasacral transcutaneous electrical neural stimulation for overactive bladder in children

OBJECTIVE

To evaluate the urodynamic changes immediately after the first session (acute effect) and after the last session of parasacral TENS in children with idiopathic OAB.

MATERIALS AND METHODS

We performed urodynamic evaluation immediately before and after the first session of parasacral TENS and immediately after the last session (7 weeks later). Only children with idiopathic isolated OAB were included. Patients with dysfunctional voiding were not included.

RESULTS

18 children (4 boys and 14 girls, mean age of 8.7) were included in the first analysis (urodynamic study before and immediately after the first session) and 12 agreed to undergo the third urodynamic study. Urodynamic before and immediately after the first session: There was no change in the urodynamic parameters, namely low MCC, low bladder compliance, presence of IDC, the average number of IDC, or in the maximum detrusor pressure after the first exam. Urodynamic after the last session: The bladder capacity improved in most patients with low capacity (58% vs. 8%). Detrusor overactivity was observed in 11 (92%) before treatment and 8 (76%) after. There was not a significant reduction in the average number of inhibited contractions after TENS (p=0.560) or in the detrusor pressure during the inhibited contraction (p=0.205).

CONCLUSION

There was no change in the urodynamic parameters immediately after the first session of stimulation. After the last session, the only urodynamic finding that showed improvement was bladder capacity.

Management of refractory overactive bladder in children by transcutaneous posterior tibial nerve stimulation: A controlled study

OBJECTIVE

To assess the objective efficacy of transcutaneous posterior tibial nerve stimulation in children presenting with overactive bladder resistant to well conducted treatment.

MATERIAL AND METHOD

This was a randomized, double-blind, controlled study on 20 children with OAB. All patients were previously treated with anticholinergic drugs associated with detrusor rehabilitation, diet advice, bladder-voiding hygiene and constipation treatment, with poor clinical results. Patients were randomized into two groups: -Group A: treatment with PTNS (n = 11). -Group B: sham treatment (n = 9). The program lasted 12 consecutive weeks with two 30-minutes sessions a week. Each patient underwent pre-stimulation urodynamic testing to validate bladder overactivity followed by a post-stimulation testing. Pre- and post-stimulation urodynamic parameters were compared in order to objectively evaluate the treatment's efficacy. The patients noted their incontinence episodes for 7 consecutive days in a diary before the beginning of the program, in the middle and at the end of it: this led to computing an incontinence score (score ranged from 0 to 13, from good to poor). The difference between the pre-stimulation and post-stimulation score enabled to express clinical results in terms of poor (less than a 3-point decrease), medium (a 3 to 5-point decrease), good (6 to 8-point decrease), very good (final score ranged between 0 and 3). Children were questioned regarding their impression of being stimulated or not.

RESULTS

In Group A, there were five very good clinical results (45%), one medium (10%) and five poor results (45%). In group B, nine very good results (66%) and three poor results (33%) were noted. Regarding urodynamic testing, volume voided during urgency (184 mL to 265 mL), maximal cystomanometry volume (215 mL to 274 mL) and volume at the onset of the first overactive detrusor contraction (ODC) (48 mL to 174 mL) were significantly increased in Group A (p = 0.002, p = 0.024 and p = 0.001) and maximal bladder pressure during ODC had decreased (61 to 46) (p = 0.042). 85% children in group A thought they were being stimulated vs. 70% in group B.

CONCLUSION

Even though we noticed urodynamics improvements in group A, which objectively supports the efficacy of TCTPNS, clinical results remained the same between the two groups. In spite of the small size of our sample, this underlines the placebo effect of any type management in this pediatric population. Studying precisely the maximal useful voltage and duration of stimulation should then be relevant in order to yield maximal benefits from this easy-to-use procedure.

The effectiveness of transcutaneous electrical neural stimulation therapy in patients with urinary incontinence resistant to initial medical treatment or biofeedback

OBJECTIVE

While there are many options for children with treatment refractory urinary incontinence, there is no single accepted method. This study's aim was to prospectively evaluate the effect of transcutaneous electrical nerve stimulation in children with urinary incontinence resistant to standard medical, urological therapy and/or biofeedback.

PATIENTS & METHODS

This study was performed at a university hospital. For inclusion, patients >5 years of age first underwent evaluation with urinary ultrasonography, uroflow-electromyogram and voiding diaries. Treatment with biofeedback, alpha adrenergic blockers, anticholinergics and/or urotherapy was commenced according to uroflow-EMG and voiding diary findings. Patients with partial or no response to this standard therapy were then included in this study, performed between April 2012 and February 2014. Patients with anatomical or neurological causes for urinary incontinence were excluded. TENS was performed on S3 dermatome, every day for 3 months. Each session lasted 20 min with a frequency of 10 Hz and generated pulse of 350 μs. Intensity was determined by the child's sensitivity threshold. Medical treatment and urological therapy was continued during TENS. Uroflow parameters (voiding volume as percentage of expected bladder capacity, Qmax, Qave, flow and voiding time, postvoiding residual urine) and urinary system symptoms (presence of urinary tract infection, frequency, urge incontinence, fractionated voiding and constipation) were compared immediately before commencement and immediately after the completion of 3 months of TENS.

RESULTS

Twenty-seven patients were included in this study (4 males, 23 females). Patients' average age was 7.2 years, 11 had overactive bladder and 16 had dysfunctional voiding. Comparison of urinary system symptoms and uroflow parameters before and after TENS are shown in Table. After 3 months of TENS; a statistically significant decrease was observed in the number of patients with frequency, urge incontinence, urinary tract infections and constipation. There was a decrease in the number of patients with fractionated voiding, although this change was not statistically significant. Similarly, for uroflow-EMG parameters; bladder capacity, Qmax, Qave and flow time increased while voiding time and PVR decreased. Changes seen in bladder capacity, Qmax and PVR were statically significant, while other changes were not. Patients' response rates after 3 months of TENS were; complete response in 70.4%, partial response in 22.2% and no response in 7.4%.

CONCLUSION

This study has shown that transcutaneous electrical nerve stimulation is a promising treatment option for standard-treatment refractory children with urinary incontinence.

[Tibial nerve transcutaneous stimulation for refractory idiopathic overactive bladder in children and adolescents]

INTRODUCTION

The purpose of this study was to evaluate safety and tolerability of transcutaneous tibial nerve stimulation (TENS) in patients under 15years of age with refractory overactive bladder.

MATERIALS AND METHODS

A retrospective analysis was conducted on outcomes of TENS (1daily 20-minute session, 10Hz) in patients with refractory overactive bladder, excluding patients with neurogenic bladder. Treatment efficacy was evaluated on symptomatic improvement and voiding schedule. Healing was defined as following: no recurrence of urinary tract infection, normal urodynamic voiding parameters, no nighttime continence disorder, normal uroflowmetry.

RESULTS

Nineteen consecutive patients with refractory overactive bladder were treated from November 2010 to March 2012 (11girls, 8boys, age 12.1±2.7 years). Three patients reported only daytime voiding disorders, the others reported daytime and nighttime voiding disorders. Ten patients reported febrile urinary tract infection (1 boy, 9 girls). The average length of treatment was 6 months. Two patients were lost to follow-up. Thirteen patients had only tibial TENS; 3 patients had tibial TENS and trospium chloride or desmopressin. At 1-month assessment, 16 patients out of 17 (94%) reported symptomatic improvement. At the end of treatment, 12 patients out of 17 (70%) met healing criteria (5 boys, 7girls), without relapse within 9 months. Three boys (18%) had partial improvement (no daytime wetting, but increased daytime frequency). No patient reported side effects.

CONCLUSION

Tibial TENS is a safe, non invasive and effective treatment in refractory overactive bladder in children. The success rate is 70%, with no side effect and no relapse at the end of the treatment in our study.

Effects of transcutaneous neuromodulation (TENS) on overactive bladder symptoms in children: a randomized controlled trial

BACKGROUND

The aim of the present study was to investigate whether addition of transcutaneous electrical nerve stimulation (TENS) treatment improves the results of standard urotherapy in children with overactive bladder (OAB) symptoms.

MATERIAL AND METHODS

Sixty-two children with symptoms of OAB and incontinence were included. The children were randomized either to standard urotherapy treatment alone or a combination of standard urotherapy and TENS. The effect variables were taken from a voiding-drinking diary: number of voiding, number of incontinence episodes, and maximum voided volume.

RESULTS

Both treatment groups had good treatment results, with no significant difference between the groups. In the standard treatment group 13/28 (46%) were completely dry and 11/28 (40%) had a decrease in incontinence episodes, compared to 16/24 (67%) and 3/24 (13%), respectively, in the standard+TENS group (p=0.303). The number of voiding decreased in two-thirds of the patients in both groups. However, maximal voided volume only increased in the standard treatment group. Subjectively 72% and 80% considered themselves significantly improved or free of symptoms. Previous treatment was registered in 15/55 (27%). All efficacy variables decreased in those with previous treatment, but with no difference between the standard and standard+TENS treatment groups. The only difference noted was when comparing the children without previous treatment in the groups: a significantly higher proportion were completely dry in the TENS group (12/18 [71%] versus 10/22 [48%], p=0.05).

CONCLUSION

Our results showed no significant difference overall in treatment response to OAB symptoms between urotherapy only and urotherapy+TENS, whereas a tendency to difference was found in children without previous treatment. Thus with good urotherapy support, TENS only seems to have marginal additional effects on OAB symptoms.

Electrical stimulation for lower urinary tract dysfunction in children: a systematic review of the literature

AIMS

To review studies using electrical neural stimulation (ENS), to treat children with non-neurogenic lower urinary tract dysfunctions (LUTD), and to establish the efficacy of this treatment.

METHODS

This review was based on an electronic search of the MEDLINE database and the Cochrane Central Search library, from January 1990 to March 2010.

INCLUSION CRITERIA

(1) participants aged 0-17 years, (2) participants with a diagnosis of LUTD not related to congenital abnormalities or neurological disease, (3) English language, and (4) treatment by ENS.

RESULTS

Seventeen papers were evaluated. Type of ENS varied among studies: sacral transcutaneous ENS in seven, sacral implanted device in four, posterior tibial percutaneous in three, and anogenital, endoanal, and intravesical in one each. There were two randomized clinical trials. Clarity regarding the LUTD being treated was variable. The populations studied were not homogeneous. The duration of treatment and the number of sessions a week were variable among the studies. Electrical parameters used also varied. A range of subjective and objective measures was used to measure treatment success. Rates of complete resolution of the symptoms of OAB, urgency, and daytime incontinence ranged from 31% to 86% [Trsinar and Kraij, Neurourol Urodyn 15: 133-42, 1996; Hagstroem et al., J Urol 182: 2072-8, 2009], 25% to 84% [Hoebeke et al., J Urol 168: 2605-8, 2002; Lordêlo et al., J Urol 182: 2900-4, 2009], 13% to 84% [Malm-Buatsi et al., Urology 70: 980-3, 2007; Lordêlo et al., J Urol 184: 683-9, 2010], respectively. For sacral transcutaneous ENS recurrence ranged from 10% to 25%. Apart from the sacral implantation studies, any reported side effects were mild and transitory.

CONCLUSIONS

The literature in the area of interest is sparse. Parasacral TENS has been shown to be more effective than sham in randomized trials in treating OAB. This deserves further research to elucidate the optimal parameters and the children for whom it is most useful.

Electrical nerve stimulation for overactive bladder in children

Overactive bladder (OAB) is a urological condition that is frequently observed in children and requires treatment. Standard urotherapy is usually the first line of treatment; however, children with severe OAB do not respond to this therapy. Antimuscarinic drugs may be used, but complete resolution of symptoms with this medication is low. Studies, including two randomized clinical trials, have demonstrated that electrical nerve stimulation (ENS) can be used successfully for OAB in children. Electrodes have been placed in the genitals, anus, and intravesical area, and on the tibial posterior nerve, as well as used transcutaneously or implanted during a surgical procedure. This Review will discuss the use of ENS in children with OAB, with particular focus on the putative mechanisms of action, the different ENS techniques available, and clinical results for this therapy.

Current state of nerve stimulation technique for lower urinary tract dysfunction in children

PURPOSE

A variety of electrical nerve stimulation methods has been used through the years to treat lower urinary tract dysfunction. Relevant literature was reviewed to analyze techniques and available biomedical devices, technique applicability, indications and usefulness in pediatrics.

MATERIALS AND METHODS

An extensive search was performed on PubMed® and MEDLINE® for scientific publications on intravesical, transcutaneous, sacral spine and root, and tibial nerve stimulation in children with lower urinary tract dysfunction of nonneurogenic and neurogenic origin. Relevant articles and controlled studies in adult patients were also considered. The search covered the period 1990 to 2009 and we found approximately 400 articles, of which 29 related to pediatrics.

RESULTS

Due to feasibility problems with placebo studies the majority of the studies were noncontrolled, some of them clinical trials on acute urodynamic changes during electrical stimulation or experimental research in animals. Overall only a few randomized trials were found. Regarding types of electrostimulation and indications in children the recent literature emphasizes stimulation far from the anal-genital region, such as sacral transcutaneous electrical nerve stimulation, mainly for refractory overactive bladder. Intravesical stimulation is the procedure of choice to enhance sensation in patients with incomplete neurogenic lesions. Percutaneous tibial nerve stimulation is tolerated by children but has been poorly studied. Sacral neuromodulation using implanted devices remains questionable and needs further clarification of its indications. Magnetic stimulation has rarely been used in children to date. More experimental studies are needed to assess the method of action and refine the parameters of stimulation.

CONCLUSIONS

Clinical controlled trials vs sham devices and predictable variables for successful response are urgently needed to address an apparently renewed focus on the use of nerve stimulation in the treatment of pediatric lower urinary tract symptoms.

Transcutaneous electrical nerve stimulation in children with overactive bladder: a randomized clinical trial

PURPOSE

We evaluated the effectiveness of parasacral transcutaneous electrical nerve stimulation to treat overactive bladder in children. We designed a prospective randomized trial with sham control for this evaluation.

MATERIALS AND METHODS

We prospectively randomized 25 girls and 12 boys with an average age of 7.6 years (range 4 to 12) into the test (active treatment) or sham (superficial scapular electrical stimulation) group. A total of 20 sessions, 20 minutes each (10 Hz) were performed 3 times weekly. The criteria used to evaluate the rate of success were 1) self-reported cure, or significant, mild or no improvement; 2) visual analogue scale (level of success 0 to 10); 3) percent improvement; 4) modified Toronto score; and 5) maximum voided volume, average voided volume and number of voids daily based on bladder diary entries. After completion of the 20 sessions controls who were not cured underwent active treatment.

RESULTS

A total of 21 patients in the test group and 16 in the sham group underwent treatment. Among the active treatment group 61.9% of parents reported cure. In the sham group no parent reported cure (p <0.001). Regarding visual analogue scale a score of 10 was indicated by 13 parents in the test group, while 1 parent in the sham group indicated a score of 9 (p = 0.002). Additionally 100% improvement was reported by 12 parents in the test group and no parent in the sham group. Toronto score improved significantly in the test group (p <0.001) and sham group (p = 0.008). However, the score was reduced more significantly in the test group compared to the sham group (p = 0.011). In the test group average and maximum voided volumes showed a statistically significant increase and the number of voids daily decreased. After superficial scapular electrical stimulation 13 of the 16 patients who underwent parasacral transcutaneous electrical nerve stimulation were cured.

CONCLUSIONS

This is the first known randomized clinical trial to demonstrate that parasacral transcutaneous electrical nerve stimulation is effective in the treatment of children with overactive bladder.

Prospective study of transcutaneous parasacral electrical stimulation for overactive bladder in children: long-term results

PURPOSE

We evaluated the long-term success of transcutaneous parasacral electrical stimulation for overactive bladder in children.

MATERIALS AND METHODS

We prospectively evaluated children who underwent transcutaneous parasacral electrical stimulation for overactive bladder. All patients had symptoms of overactive bladder, bell curve in uroflowmetry and low post-void residual urine. The procedure was performed using a frequency of 10 Hz for 20-minute sessions 3 times weekly for a maximum of 20 sessions. Initial and long-term (more than 6 months) success rates were evaluated.

RESULTS

Transcutaneous parasacral electrical stimulation was performed in 36 girls and 13 boys with a mean age of 10.2 years (range 5 to 17). Mean followup was 35.3 months (range 6 to 80). Before treatment urgency, daytime incontinence and urinary tract infection were seen in 100%, 88% and 71% of cases, respectively. Initial success (full response) was demonstrated in 79% of patients for urgency, 76% for incontinence and 77% for all symptoms. Continued success was seen in 84% of patients for urgency, 74% for daytime incontinence and 78% for all symptoms. If the 30 patients with at least 2 years of followup were considered, treatment was successful in 73%. Recurrence of symptoms after a full response was seen in 10% of cases. Two of 33 patients (6%) with urinary tract infection before the procedure still had infection after treatment.

CONCLUSIONS

Transcutaneous parasacral electrical stimulation is well tolerated, and demonstrates short and long-term effectiveness in treating overactive bladder in children. Symptoms eventually will recur in 10% of patients.

Long-term efficacy of percutaneous tibial nerve stimulation for different types of lower urinary tract dysfunction in children

PURPOSE

We evaluated the efficacy of percutaneous tibial nerve stimulation for different types of pediatric lower urinary tract dysfunction.

MATERIALS AND METHODS

A total of 14 children with idiopathic overactive bladder, 14 with dysfunctional voiding, 5 with underactive bladder, 4 with underactive valve bladder and 7 with neurogenic bladder resistant to conventional therapy underwent percutaneous tibial nerve stimulation weekly for 12 weeks. The stimulation effect was evaluated by comparing bladder diary, flowmetry and urinalysis before and after treatment. Improved patients were followed by bladder diary and urinalysis. Followup data at 1 and 2 years were compared with those obtained after stimulation. Data were analyzed using Fisher's exact test.

RESULTS

Symptom improvement was significantly greater in nonneurogenic than in neurogenic cases (78% vs 14%, p <0.002). Of patients 18% with underactive bladder and 50% with underactive valve bladder were unresponsive. Of 14 overactive bladder cases 12 and all 14 of dysfunctional voiding were improved (p not significant). Of improved patients 5 of 12 with overactive bladder and 12 of 14 with dysfunctional voiding were cured (p <0.01). On uroflowmetry voided volume and post-void residual urine became normal in a greater number of dysfunctional voiding than overactive bladder cases (57% vs 20% and 57% vs 25%, each p not significant). At 1 year of followup the cure rate was greater in dysfunctional voiding than in overactive bladder cases (71% vs 41%) and it remained the same at the 2-year evaluation. Chronic stimulation was necessary to maintain results in 29% of dysfunctional voiding and 50% of overactive bladder cases.

CONCLUSIONS

Percutaneous tibial nerve stimulation is reliable and effective for nonneurogenic, refractory lower urinary tract dysfunction in children. Efficacy seems better in dysfunctional voiding than in overactive bladder cases. There is evidence that percutaneous tibial nerve stimulation should be part of the pediatric urology armamentarium when treating functional incontinence.