Early experience with transurethral electrical bladder stimulation

Effects of intravesical electrical stimulation therapy on urodynamic patterns for children with spina bifida: a 10-year experience

OBJECTIVE

Intravesical electrical stimulation (IVES) has been performed for various purposes in children with a neurogenic bladder. We evaluated the results of IVES on urodynamic study parameters in children with spina bifida.

METHODS

We retrospectively analyzed the cases of 88 children who received IVES between August 1999 and May 2010 and whose comparative urodynamic data were available before and after treatment. According to the pre-IVES urodynamic study, children were divided into 3 groups: detrusor overactivity, detrusor underactivity and acontractile detrusor. We investigated the changes in detrusor function, bladder capacity and detrusor-sphincter dyssynergia.

RESULTS

In the group showing detrusor overactivity, the bladder had a synergic pattern in 41.7%, and normal detrusor function was observed in 16.7% of them. Bladder capacity increased after IVES therapy, especially in those who started therapy before 18 months of age (p = 0.019). Detrusor-sphincter dyssynergia was resolved in 55.6%. In the acontractile detrusor group, detrusor contraction ability increased in 48%, but bladder capacity did not.

CONCLUSIONS

Appropriate candidates for this treatment need to be carefully selected.

Intravesical Electrotherapy for Neurogenic Bladder Dysfunction: A 22-Year Experience

PURPOSE

Intravesical electrotherapy was previously shown to be effective for improving bladder capacity and compliance. We evaluated our 22-year experience with this therapy in patients with neurogenic bladder.

MATERIALS AND METHODS

The charts of 405 patients who received intravesical electrotherapy were reviewed. Cystometrograms were performed at the start of each treatment series. Bladder capacity and pressure were determined for each patient before and after therapy. Patients were also questioned regarding the sensation of bladder filling.

RESULTS

From 1985 to 2006, 372 patients with an average age of 5.5 years (range 0 to 43) had followup information available and were included for evaluation. Patients received a median of 29 treatment sessions (range 2 to 197). Mean patient followup was 6.6 years (range 0 to 19.7). Of the 372 patients 286 (76.9%) had a 20% or greater increase in bladder capacity after treatment. In this subset of patients bladder storage pressure at capacity was normal (less than 40 cm water) in 74.4% (213 of 286). Of the 17.2% of patients (64 of 372) who had no change in bladder capacity 81.21% (52 of 64) had normal bladder storage pressures after treatment. Bladder sensation was developed and sustained in 61.6% of patients (229 of 372), including 33.6% in the first series.

CONCLUSIONS

Bladder stimulation is effective for increasing bladder capacity without increasing storage pressure in a majority of patients. This technique is safe and effective for improving bladder compliance. Some patients also have improved sensation of bladder filling and they should be able to catheterize when feeling full rather than by the clock.

Modulation of the micturition reflex pathway by intravesical electrical stimulation: an experimental study in the rat

Intravesical electrical stimulation (IVES) is used clinically to improve bladder evacuation in patients with inadequate micturition contractions. The procedure involves field stimulation of Adelta bladder mechanoreceptor afferents resulting in a prolonged enhancement of the micturition reflex. The aim of the present experimental study in the rat was to identify the site for this neuromodulation, whether it was due to sensitization of bladder mechanoreceptors, to enhancement of transmission in the central micturition reflex pathway, or to improved effectiveness of the peripheral motor system of the bladder. The experiments were performed on female rats, anesthetized by alpha-chloralose. Multi-unit afferent or efferent activity was recorded from bladder pelvic nerve branches during repeated cystometries before and after IVES. The specific antagonist CPPene was used to block central glutaminergic receptors of NMDA type. Micturition threshold volume decreased significantly after IVES. The afferent threshold volume, peak response, and pressure sensitivity were unchanged as were the peak efferent activity and bladder contractility. There was no efferent activity until just before the micturition contraction. The IVES-induced decrease in micturition threshold was blocked by prior administration of the NMDA (N-methyl-D-aspartic acid) antagonist CPPene (3-(2-carboxypiperazin-4-yl)-1-propenyl-1-phosphonic acid). The findings indicate that the IVES-induced modulation of the micturition reflex is due to an enhanced excitatory synaptic transmission in the central micturition reflex pathway. The observed modulation may account for the clinical beneficial effect of IVES treatment.

Optimal conditions for the long-term modulation of the micturition reflex by intravesical electrical stimulation: an experimental study in the rat

OBJECTIVE

To determine whether induced bladder contractions influence the modulation by intravesical electrical stimulation (IVES) of the micturition reflex in anaesthetized rats, and to identify the optimal IVES frequency and duration.

MATERIALS AND METHODS

Seventy-six adult female rats, anaesthetized by alpha-chloralose. were divided into four groups to study the effect of: (i) IVES in combination with bladder contractions; (ii) bladder contractions alone; (iii) IVES frequency; and (iv) IVES duration. IVES was administered using a catheter electrode in the bladder. The effect of various IVES procedures was evaluated by determining the micturition threshold volume obtained from repeated cystometries before and after stimulation.

RESULTS

Administering IVES with standard parameters induced a significant decrease in the micturition threshold volume for about an hour. There was no difference in outcome between IVES with the bladder filled and contracting during the stimulation or empty and not contracting. Imposed bladder contractions per se had no effect on the micturition threshold volume. IVES at low frequencies (< or = 20 Hz) had a better modulatory effect than higher frequencies and the optimum duration of IVES was 5 min.

CONCLUSIONS

Evoked bladder contractions did not improve the IVES-induced modulation of the micturition reflex. These findings might help to improve the clinical application of the IVES procedure.

Restoration of micturition in patients with acontractile and hypocontractile detrusor by transurethral electrical bladder stimulation

The aim of transurethral electrical bladder stimulation (TEBS) treatment in patients with diminished detrusor contractility is to attain complete voiding, i.e., micturition without residual urine, which is under volitional control. In contrast to other types of electrical bladder stimulation, the physiological basis for this kind of treatment is sensitizing of the bladder mechanoreceptor afferents. The latency of afferent stimuli in normal conditions indicates that myelinated A-delta-fibers are used for neurotransmission from these mechanoreceptors. Forty-eight patients with hypocontractile or acontractile detrusor underwent intravesical electrical stimulation. All patients had a history pointing to neurogenic pathology. Forty patients had an acontractile and 8 a hypocontractile bladder. Prior to therapy, the mean residual urine volume was 461 ml. After stimulation, 32 of 48 patients were able to void with a mean residual of 57 ml. Detrusor contraction was achieved in 39% and bladder sensation was perceived by 75% of patients who failed these conditions before treatment. Following therapy, 19 of 35 patients were able to empty their bladder without the previously needed catheterization. Side effects were epididymitis in 1 and cystitis in 7 patients.

Transurethral electrical bladder stimulation: a followup report

Transurethral electrical bladder stimulation (TEBS) initially proposed to rehabilitate the neurogenic bladder has been promoted in the United States since the mid 1980s. The ultimate goal of TEBS is volitional voiding. Since January 1989 we performed 938 sessions of stimulation comprising 64 TEBS series in 25 patients with neurogenic bladders. A cystometrogram was performed before each series of stimulation to monitor progress, and at the time of this review parental impressions of the stimulation were obtained by a telephone interview questionnaire. The initial evaluation cystometrogram before stimulation revealed that 18 patients (72%) had bladder contractions. After TEBS 24 patients (96%) manifest contractions. Before stimulation only 3 children sensed the contractions, while during stimulation half of the patients perceived the contractions. A cystometrogram performed before each series demonstrated a greater than 20% increase in the age adjusted bladder capacity in 6 of the 18 patients (33%) with serial studies. Improvements in the end filling pressure defined by clinically significant decreases were observed in 5 of these patients (28%). Results of the telephone questionnaire revealed that the parents perceived a benefit from stimulation more often than the urodynamic studies could confirm. In our experience TEBS is a time-consuming, labor intensive technique. The limited urodynamic benefits our patients achieved have not materially altered the daily voiding regimen and, because of these factors, we are not enrolling any new patients in our TEBS program.