Transcutaneous electrical nerve stimulation in the treatment of neurological patients with urinary symptoms

Transcutaneous electrical nerve stimulation and catheter-related bladder discomfort following transurethral resection of bladder tumour: A randomised controlled trial

BACKGROUND

Catheter-related bladder discomfort (CRBD) is problematic in patients with a urinary catheter. Transcutaneous electrical nerve stimulation (TENS) is a non-invasive analgesic modality used to relieve various types of pain.

OBJECTIVES

We evaluated the effect of TENS on CRBD after transurethral resection of bladder tumours (TURBT).

DESIGN

A randomised controlled trial.

SETTING

A large university tertiary hospital, from October 2022 to March 2023.

PATIENTS

Patients requiring urinary catheterisation after TURBT.

INTERVENTION

In this randomised controlled trial, patients were randomly allocated to the TENS (n  = 56) or control (n  = 56) groups. CRBD manifests as a burning sensation with an urge to void or discomfort in the suprapubic area. Moderate to severe CRBD was defined as patients self-reporting CRBD symptoms with or without behavioural response, including attempts to remove the urinary catheter, intense verbal reactions, and flailing limbs. TENS was performed from the end of surgery to 1 h postoperatively.

MAIN OUTCOME MEASURE

The primary endpoint was considered moderate to severe CRBD immediately postoperatively. Secondary endpoints included moderate to severe CRBD at 1, 2 and 6 h postoperatively. Additionally, postoperative pain, patient satisfaction, and TENS-related adverse effects were evaluated.

RESULTS

Moderate to severe CRBD immediately postoperatively was significantly less frequent in the TENS group than in the control group: 10 (17.9%) vs. 34 (60.7%); P < 0.001; relative risk (95% CI) = 0.294 (0.161 to 0.536); absolute risk reduction = 0.43; number needed to treat = 2.3. Moderate to severe CRBD differed between the two groups at 1 h postoperatively: 1 (1.8%) vs. 16 (28.6%); P < 0.001; relative risk = 0.06 (95% CI 0.01 to 0.46); absolute risk reduction = 0.27; number needed to treat = 3.7. The TENS group exhibited a significantly lower score for postoperative pain at 1 h (1.8 ± 0.6 vs. 2.2 ± 0.4; P < 0.001, mean difference (95% CI) = 0.4 (0.2 to 0.6) and a higher score for patient satisfaction, 5.0 (4.0 to 6.0) vs. 3.0 (3.0 to 4.0); P < 0.001; median difference (95% CI) = 2.0 (1.0 to 2.0).

CONCLUSIONS

TENS reduced moderate to severe CRBD, decreased postoperative pain, and increased patient satisfaction after TURBT.

CLINICAL TRIAL REGISTRY

Clinical Research Information Service (KCT0007450).

VISUAL ABSTRACT

http://links.lww.com/EJA/B12.

Avicenna and clinical experiences in Canon of Medicine

Avicenna used his medical knowledge and experience of scientists from different nations to create a new style in medicine. For this reason, his textbook, Canon of Medicine, has been considered a medical reference in all universities worldwide for centuries. In this article, some valuable and interesting diagnostic and therapeutic clinical experiences mentioned in the Canon of Medicine are described in five sections. This research was conducted to review Avicenna’s specific clinical observations and interventions in PubMed, Google Scholar, and Scopus databases using the keywords “Avicenna” and “Canon of Medicine”. In this article, we presented several examples of diagnostic and therapeutic clinical experiences mentioned in the Canon of Medicine in 5 areas, including semiology, therapeutic strategy, urology, neurology, obstetrics, and gynecology. Canon of Medicine, as a complete medical series containing the medical experiences from different nations and Iranian medical scientists, has influenced the world’s medical knowledge for several centuries. Some of Avicenna’s clinical and experimental views can be useful from both a historical point of view and new research.

Efficacy of Transcutaneous Electrical Nerve Stimulation in the Management of Neurogenic Overactive Bladder: A Randomized Controlled Trial

OBJECTIVE

The aim of the study was to investigate the therapeutic effect of transcutaneous electrical nerve stimulation on neurogenic overactive bladder that is refractory to pharmacotherapy.

METHODS

This randomized trial recruited 83 participants with neurogenic overactive bladder that were nonresponsive to 3-mo first-line anticholinergic drug treatment. Participants were randomized into treatment and control groups. Transcutaneous electrical nerve stimulation current consisting of biphasic square wave with pulse durations of 150 μs and pulse frequency set at 20 Hz were applied to for 30 mins once a day for 90 days. Stimulation was provided over the lateral aspect of the sacrum bilaterally of the electrodes. Patients in the transcutaneous electrical nerve stimulation group stopped taking the anticholinergic drugs. The control group continued to receive anticholinergic drugs for 90 days. The participants' Overactive Bladder Symptom Score, the Medical Outcomes Study 36-Item Short-Form Health Survey scores, urodynamic values, and voiding diary data were assessed before and after the therapy.

RESULTS

The transcutaneous electrical nerve stimulation treatment group had significantly decreased Overactive Bladder Symptom scores compared with the control group (P < 0.001); in addition, half of the Medical Outcomes Study 36-Item Short-Form Health Survey scores were significantly improved in the transcutaneous electrical nerve stimulation group (P < 0.05). The patients treated with transcutaneous electrical nerve stimulation improved significantly voiding diary parameters at P < 0.05. Similarly, urodynamic values at P < 0.05 favored the experimental group over the control group.

CONCLUSIONS

Applying daily transcutaneous electrical nerve stimulation over the sacral region for 90 days to patient with neurogenic overactive bladder improved overactive bladder symptoms of patients whose response to anticholinergic drugs is far inferior.

TO CLAIM CME CREDITS

Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME.

CME OBJECTIVES

Upon completion of this article, the reader should be able to: (1) Determine the therapeutic effect of transcutaneous electrical nerve stimulation (TENS) on neurogenic overactive bladder (NOAB); (2) Demonstrate the effectiveness of reflex suppression of the bladder using the TENS applied over the sacral region as a stimulation location; and (3) Confirm the TENS method using biphasic square waves with pulse durations of 150 μs and pulse frequencies of 20 Hz as applied is shown to be superior to anticholinergic drugs in managing NOAB.

LEVEL

Advanced.

ACCREDITATION

The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.The Association of Academic Physiatrists designates this journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Transcutaneous tibial nerve home stimulation for overactive bladder in women with Parkinson's disease: A randomized clinical trial

AIMS

This study aims to investigate the efficacy of transcutaneous tibial nerve home stimulation for overactive bladder (OAB) in women with Parkinson's disease (PD).

METHODS

The current study is a prospective, randomized, double-blind, sham-controlled trial. Home intervention was carried out and assessments were conducted at a tertiary hospital in South Brazil. Women with PD and OAB symptoms were included in the study. Patients were randomly divided into two groups: (1) stimulation and (2) sham. Both groups underwent intervention at home for 12 weeks. Patients were evaluated at baseline and at 12 weeks (end of intervention), 30- and 90-day follow-up. The primary outcome was the mean reduction in the number of urgency incontinence episodes, and secondary outcomes included daytime and nighttime urinary frequency, urinary urgency episodes, use of pad (reported in a 24-h bladder diary), OAB-V8 and King's Health Questionnaire scores, and maintenance of symptom relief after discontinuation of the intervention.

RESULTS

In total, 30 consecutive patients completed the study (15/group). The stimulation group showed a reduction in nighttime urinary frequency (0.9 ± 0.6), urinary urgency (1.0 ± 1.2), urgency incontinence episodes (0.5 ± 0.6), use of pads (1.3 ± 1.2), and OAB-V8 (1.3 ± 1.2) and King's Health Questionnaire scores. In a 30-day and 90-day follow-up, 8 (53.3%) and 5 (33.3%) stimulation patients, respectively, reported full maintenance of symptom relief after discontinuation of the intervention. Stimulation patients presented a statistically significant improvement of symptoms as compared with sham patients (p = .001).

CONCLUSIONS

Transcutaneous tibial nerve home stimulation can be used in clinical practice as an effective nonpharmacological resource for the reduction of OAB symptoms in women with PD, and the resulting relief seems to persist in the follow-up (30 and 90 days).

Transcutaneous tibial nerve stimulation to treat urgency urinary incontinence in older women: 12-month follow-up of a randomized controlled trial

INTRODUCTION AND HYPOTHESIS

Urgency urinary incontinence (UUI) is highly prevalent in elderly individuals and has a great impact on quality of life. Transcutaneous tibial nerve stimulation (TTNS) can be an effective treatment option for UUI in older women.

METHODS

This is a single-center randomized clinical trial with a 12-month follow-up involving 106 women > 60 years of age. Kegel exercises and bladder retraining were performed alone or in combination with TTNS, which consisted of using a transcutaneous electrical nerve stimulator for 30 min once a week for 12 weeks with the following settings: continuous mode, 10 Hz, 200 ms, and 10 to 50 mA (according to hallux mobilization). Responders to therapy who experienced failure during follow-up were invited for a 3-week protocol with the same parameters as those used for the initial therapy. Patients were evaluated at baseline, 4 weeks after the 12-week protocol, and every 3 months for 12 months, through subjective satisfaction questionnaires, a 3-day bladder diary and the International Consultation on Incontinence Questionnaire-Short Form. King's Health Questionnaire was applied pretreatment and 4 weeks after the last session of the 12-week protocol.

RESULTS

A total of 101 women completed the initial 12-week protocol. TTNS patients reported 66.7% subjective global satisfaction vs. 32.0% in the control group (p < 0.001). The TTNS group showed statistically significant improvement in quality of life (QoL) and UUI parameters compared with the control group. Forty-eight patients were satisfied after the 12-week protocol and completed the 12-month follow-up (32 in the TTNS group and 16 in the control group). A total of 80.5% of responders to TTNS were still satisfied at the end of the 12-month follow-up vs. 30.8% in the control group (p = 0.009).

CONCLUSION

TTNS is effective at the 12-month follow-up for the treatment of UUI in elderly women.

Nocturia and Nocturnal Polyuria in Neurological Patients: From Epidemiology to Treatment. A Systematic Review of the Literature

CONTEXT

Nocturia is among the most common and bothersome lower urinary tract symptoms (LUTS), but there is no clear consensus on how to identify and manage this symptom in the neurological population.

OBJECTIVE

To systematically review the literature about nocturia in neurological patients.

EVIDENCE ACQUISITION

Studies were identified by electronic search of Cochrane and Medline databases. The studies were included if their participants had acquired neurological pathology among multiple sclerosis (MS), Parkinson's disease (PD), stroke, spinal cord injury (SCI), and reported data on the epidemiology, aetiology, diagnosis, or treatment of nocturia. An independent extraction of the articles was performed by two authors using predetermined datasets, including quality-of-study indicators.

EVIDENCE SYNTHESIS

A total of 132 studies were included; 46 evaluated the epidemiology of nocturia, 28 the possible aetiologies, 10 the diagnostic tools, and 60 the treatments. Nocturia prevalence ranged from 15% to 96% depending on the pathology and definition used. It was one of the most frequently reported LUTS in PD and stroke patients. Several validated questionnaires were found to screen for nocturia in this population. Causalities were numerous: LUT, renal, sleep, cardiovascular dysfunctions, etc. Treatments targeted these mechanisms, with an overall risk of bias assessed as high or serious. The highest level of evidence was seen in MS patients: pelvic floor muscle training, cannabinoids, and desmopressin were effective, but not melatonin. In stroke patients, transcutaneous sacral and transcutaneous tibial nerve stimulation (TTNS) improved nocturia; in PD patients, TTNS, solifenacin, and rotigotine did not.

CONCLUSIONS

Nocturia is highly prevalent in patients with neurological disorders. Causalities and treatments are not different from the general population, but are poorly studied in neurological patients.

PATIENT SUMMARY

In this report, we looked at the published studies about nocturia-the fact of waking to void during the hours of sleep-in patients with neurological diseases. We found that nocturia is very frequent in this population, that the causes are the same as in the general population but may be combined, and that treatments are also the same but have an overall weak level of evidence. We conclude that more research is needed on this topic.

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

Objective:

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

Methods:

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

Results:

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

Conclusions:

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

Level of evidence:

4.

Effects of Transcutaneous Electrical Nerve Stimulation at Two Frequencies on Urinary Incontinence in Poststroke Patients: A Randomized Controlled Trial

OBJECTIVE

The objective of this study was to compare the effects of two frequencies of transcutaneous electrical nerve stimulation (TENS) on urinary incontinence caused by stroke.

METHODS

Eighty-one patients with poststroke urinary incontinence were recruited and randomized into the following three groups with a 1:1 ratio: a 20-Hz TENS group, a 75-Hz TENS group, and a no-treatment control group (n = 27 per group). TENS currents were biphasic square waves with pulse durations of 150 μsecs and pulse frequencies of 20 Hz or 75 Hz and were applied for 30 mins once per day for 90 days. The positive electrodes were placed in the region of the second sacral level on opposite sides of the vertebral column; the negative electrodes were placed on the inside of the middle and lower third of the junction between the posterior superior iliac spine and the ischial node. Overactive Bladder Symptom Scores, Barthel Index, urodynamic values, and voiding diary parameters were assessed before and after 90 days.

RESULTS

The patients treated with 20 Hz had superior Overactive Bladder Symptom Scores, Barthel Index totals, urodynamic values, and voiding diary parameters (P < 0.05). In the 75-Hz group, values were statistically improved compared with the no-treatment group (P < 0.05), but the results were significantly inferior to those of the 20-Hz group (P < 0.05).

CONCLUSIONS

Twenty-hertz TENS improved incontinence symptoms and promoted activities of daily living better than 75-Hz TENS. These results will aid future research regarding TENS parameters.

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

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

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

Purpose

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

Patients and methods

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

Results

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

Conclusion

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

Long-term TENS treatment decreases cortical motor representation in multiple sclerosis

This study investigated the effects of a long-term transcutaneous electrical nerve stimulation (TENS) treatment on cortical motor representation in patients with multiple sclerosis (MS). In this double-blind crossover design, patients received either TENS or sham stimulation for 3 weeks (1h per day) on the median nerve region of the most impaired hand, followed by the other stimulation condition after a washout period of 6 months. Cortical motor representation was mapped using transcranial magnetic stimulation (TMS) at the baseline and after the 3-week stimulation protocol. Our results revealed that 3 weeks of daily stimulation with TENS significantly decreased the cortical motor representation of the stimulated muscle in MS patients. Although the mechanisms underlying this decrease remain unclear, our findings indicate that TENS has the ability to induce long-term reorganization in the motor cortex of MS patients.

The effect of long-term TENS on persistent neuroplastic changes in the human cerebral cortex

The long-term effect of daily somatosensory stimulation with transcutaneous electrical nerve stimulation (TENS) on reorganization of the motor cortex was investigated in a group of neurologically intact humans. The scalp representation of the corticospinal projection to the finger (APB, ADM) and forearm (FCR, ECR) muscles was mapped by means of transcranial magnetic stimulation (TMS) before and after a 3-week intervention period, using map area and volume, and topographical overlaps between the cortical motor representations of these muscles as primary dependent measures. Findings revealed a significant increase in cortical motor representation of all four muscles for the TENS group from pre to posttest (all, P ≤ 0.026). No significant changes in cortical motor representations were observed in the control group. The present observations highlight the potential benefit of sensory training by means of TENS as a useful complementary therapy in neurorehabilitation.

Randomized trial of transcutaneous tibial nerve stimulation to treat urge urinary incontinence in older women

INTRODUCTION

The aim of this study was to examine the efficacy of transcutaneous electrical tibial nerve stimulation (TTNS) to treat urge urinary incontinence (UUI) in older women.

MATERIAL AND METHODS

The study design was a randomized clinical trial conducted on 51 elderly women (>60 years) with UUI. All were treated with 12 weeks of bladder retraining and pelvic floor muscle exercises, and 25 were randomly selected to receive TTNS in addition to the standard therapy. The cases were evaluated at the baseline and after the end of therapy by 3-day bladder diary, quality of life questionnaires (QoL), and subjective response.

RESULTS

Of the patients, 68.0% in TTNS group reported cure or improvement vs. 34.6% in the control group (P = 0.017). TTNS showed significant improvement in most areas of QoL and in UUI parameters when compared with the control group.

CONCLUSION

TTNS is efficacious to treat UUI in older women.

Electrical stimulation of sacral dermatomes in multiple sclerosis patients with neurogenic detrusor overactivity

AIMS

Transcutaneous electrical stimulation of the dorsal penile/clitoral nerve (DPN) has been shown to suppress detrusor contractions in patients with neurogenic detrusor overactivity (NDO). However, the long-term use of surface electrodes in the genital region may not be well tolerated and may introduce hygienic challenges. The aim of this study was to assess whether electrical stimulation of the sacral dermatomes could suppress detrusor contractions in multiple sclerosis (MS) patients with NDO, hereby providing an alternative to DPN stimulation.

MATERIALS AND METHODS

A total of 14 MS patients (8 M, 6 F) with low bladder capacity (<300 ml) and a recent urodynamic study showing detrusor overactivity incontinence participated in the study. Three successive slow fill cystometries (16 ml/min) were carried out in each patient. The first filling served as control filling where no stimulation was applied. In the second and third filling electrical stimulation of either the DPN or sacral dermatomes was applied automatically whenever the detrusor pressure exceeded 10 cmH2O.

RESULTS

The control filling showed detrusor overactivity in 12 of the 14 patients. In 10 of the 12 patients one or more detrusor contractions could be suppressed with DPN stimulation. Electrical stimulation of the sacral dermatomes failed to suppress detrusor contractions in all patients.

CONCLUSIONS

Although therapeutic effects may be present from stimulation of the sacral dermatomes, we were unable to demonstrate any acute effects during urodynamics. For this reason stimulation of the sacral dermatomes is not an option in a system that relies on the acute suppression of a detrusor contraction.

Comparison of pelvic floor muscle training, electromyography biofeedback, and neuromuscular electrical stimulation for bladder dysfunction in people with multiple sclerosis: A randomized pilot study

AIM

Bladder dysfunction affects up to 90% of the multiple sclerosis (MS) population. Interventions such as Pelvic Floor Training and Advice (PFTA), Electromyography (EMG) Biofeedback, and Neuromuscular Electrical Stimulation (NMES) have received limited research attention within this population. This study aimed to determine the effectiveness of a combined programme of PFTA, EMG Biofeedback, and NMES for bladder dysfunction in MS.

METHODS

Females (n = 30) who fulfilled strict inclusion/exclusion criteria were recruited. Outcome measures (weeks 0, 9, 16, and 24) included: 3-day Voiding Diary; 24 hr Pad-Test; Uroflowmetry; Pelvic Floor Muscle Assessment; Incontinence Impact Questionnaire (IIQ); Urogenital Distress Inventory (UDI); King's Health Questionnaire (KHQ), and the Multiple Sclerosis Quality of Life-54 Instrument (MSQoL-54). Following baseline (week 0) assessment, participants were randomly allocated, under double blind conditions, to one of the three groups: Group 1 (PFTA); Group 2 (PFTA and EMG Biofeedback); and Group 3 (PFTA, EMG Biofeedback, and NMES). Treatment was for 9 weeks.

RESULTS

Baseline severity (measured by number of leaks and pad weight) showed some variation between groups, although not statistically significant (P > 0.05); with the caveat that this baseline imbalance makes interpretation difficult, a picture emerges that at week 9, Group 3 demonstrated superior benefit as measured by the number of leaks and pad test than Group 2, with Group 1 showing less improvement when compared to week 0; this was statistically significant between Groups 1 and 3 for number of leaks (P = 0.014) and pad tests (P = 0.001), and Groups 1 and 2 for pad tests (P = 0.001). A similar pattern was evident for all other outcome measures.

CONCLUSION

Results suggest that these treatments, used in combination, may reduce urinary symptoms in MS. Further research will establish the effectiveness of these interventions.