Electroacupuncture decreases c-fos expression in the spinal cord induced by noxious stimulation of the rat bladder

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

Introduction

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

Material and methods

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

Results

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

Conclusions

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

Percutaneous Tibial Nerve Stimulation in Chronic Post-Surgical Anorectal Pain: A Case Report

<b><i>Introduction:</i></b> Anorectal pain is a symptom with a negative impact on quality of life and it can sometimes develop into a chronic pain syndrome. Structural anorectal pain is treated according to the underlying pathology. In situations of chronic post-surgical pain that is refractory to conventional therapeutic approaches, percutaneous tibial nerve stimulation (PTNS) is an option. PTNS is a neurostimulation technique used in the treatment of lower urinary tract dysfunction. There has been increasing evidence of its benefits for improving other conditions, such as chronic pelvic pain (CPP) and faecal incontinence (FI). <b><i>Case Presentation:</i></b> We report a case of a 45-year-old woman with chronic post-surgical anorectal pain (CPAP) treated with PTNS. The patient reported a consistent and dramatic decrease in both the frequency and intensity of pain, assessed by the Brief Pain Inventory (BPI). A decrease in the pain interference with mood, normal work, and walking/mobility was also noted, as evaluated by BPI and EQ-5D-3L questionnaires. <b><i>Discussion:</i></b> Neuromodulation treatments have been reported as effective for anorectal pain, but reports on the use of PTNS are rare. The tibial nerve is easily accessible and provides an optimal site for neurostimulation without the need of an operating room or anaesthesia. The overall improvement observed in this case of chronic anorectal pain suggests a potential new area of research for PTNS.

Posterior Tibial Nerve Stimulation in Fecal Incontinence: A Systematic Review and Meta-Analysis

Introduction:

The present systematic review and meta-analysis aims to investigate the role of Posterior Tibial Nerve Stimulation (PTNS) in the control of Fecal Incontinence (FI).

Methods:

Two independent reviewers extensively searched in the electronic databases of Medline, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science, CINAHL, and Scopus for the studies published until the end of 2016. Only randomized clinical trials were included. The studied outcomes included FI episodes, FI score, resting pressure, squeezing pressure, and maximum tolerable pressure. The data were reported as Standardized Mean Differences (SMD) with 95% confidence interval.

Results:

Five articles were included in the present study (249 patients under treatment with PTNS and 239 in the sham group). Analyses showed that PTNS led to a significant decrease in the number of FI episodes (SMD=−0.38; 95% CI: −0.67–0.10; P=0.009). Yet, it did not have an effect on FI score (SMD=0.13; 95% CI: −0.49–0.75; P=0.68), resting pressure (SMD=0.12; 95% CI: −0.14–0.37; P=0.67), squeezing pressure (SMD=−0.27; 95% CI: −1.03–0.50; P=0.50), and maximum tolerable pressure (SMD=−0.10; 95% CI: −0.40–0.24; P=0.52).

Conclusion:

Based on the results, it seems that the prescription of PTNS alone cannot significantly improve FI.

Effects of acupuncture stimulation at different acupoints on formalin-induced pain in rats

Acupuncture is the process of stimulating skin regions called meridians or acupoints and has been used to treat pain-related symptoms. However, the pain-relieving effects of acupuncture may be different depending on acupoints. In the present study, the effects of acupuncture on behavioral responses and c-Fos expression were evaluated using a formalin test in male Sprague-Dawley rats in order to clarify the analgesic effects of three different acupoints. Each rat received manual acupuncture at the ST36 (Zusanli), SP9 (Yinlingquan) or BL60 (Kunlun) acupoint before formalin injection. Flinching and licking behaviors were counted by two blinded investigators. Fos-like immunoreactivity was examined by immunohistochemistry in the rat spinal cord. Manual acupuncture treatment at BL60 acupoint showed significant inhibition in flinching behavior but not in licking. Manual acupuncture at ST36 or SP9 tended to inhibit flinching and licking behaviors but the effects were not statistically significant. The acupuncture at ST36, SP9, or BL60 reduced c-Fos expression as compared with the control group. These results suggest that acupuncture especially at the BL60 acupoint is more effective in relieving inflammatory pain than other acupoints.

Percutaneous Tibial Nerve Stimulation (PTNS) efficacy in the treatment of lower urinary tract dysfunctions: a systematic review

Background

Percutaneous Tibial Nerve Stimulation (PTNS) has been proposed for the treatment of overactive bladder syndrome (OAB), non-obstructive urinary retention (NOUR), neurogenic bladder, paediatric voiding dysfunction and chronic pelvic pain/painful bladder syndrome (CPP/PBS). Despite a number of publications produced in the last ten years, the role of PTNS in urinary tract dysfunctions remains unclear. A systematic review of the papers on PTNS has been performed with the aim to better clarify potentialities and limits of this technique in the treatment of OAB syndrome and in other above mentioned urological conditions.

Methods

A literature search using MEDLINE and ISI web was performed. Search terms used were “tibial nerve” and each of the already mentioned conditions, with no time limits. An evaluation of level of evidence for each paper was performed.

Results

PTNS was found to be effective in 37-100% of patients with OAB, in 41-100% of patients with NOUR and in up to 100% of patients with CPP/PBS, children with OAB/dysfunctional voiding and patients with neurogenic pathologies. No major complications have been reported.

Randomized controlled trials are available only for OAB (4 studies) and CPP/PBS (2 studies). Level 1 evidence of PTNS efficacy for OAB is available. Promising results, to be confirmed by randomized controlled studies, have been obtained in the remaining indications considered.

Conclusions

PTNS is an effective and safe option to treat OAB patients. Further studies are needed to assess the role of PTNS in the remaining indications and to evaluate the long term durability of the treatment. Further research is needed to address several unanswered questions about PTNS.

Posterior tibial nerve stimulation and faecal incontinence: a review

PURPOSE

Faecal incontinence is a common and important multifactorial disorder with a range of treatment options. Over the last two decades, neuromodulation via sacral nerve stimulators has been shown to be effective for both faecal and urinary incontinence, although associated with complications. Peripheral neuromodulation, via the posterior tibial nerve, is widely used in urinary incontinence; however, its use in faecal incontinence, whilst evolving is limited to eight small heterogeneous studies.

REVIEW

These eight studies are discussed in the context of the methodology and underlying neurophysiology of peripheral neuromodulation, as are thus far unanswered questions. The eight studies include a total of 129 patients with faecal incontinence (of variable aetiology), all of whom had failed conservative management. One study was prospective and controlled, six were uncontrolled and one was retrospective and uncontrolled. Five different neuromodulatory protocols were used over six different study periods. Outcome measures varied, but short term primary endpoint success ranged from 30.0% to 83.3%. The limitations to this early evidence, whilst encouraging, are significant, and it remains to be seen whether this novel treatment modality represents the minimally invasive, well-tolerated, cost-effective and flexible panacea hoped for this common and debilitating disease. Three upcoming multicentre placebo-controlled trials will better be able to delineate its role.

Does interstitial cystitis urine include possible factors effecting the nociceptive system of the spinal cord?

INTRODUCTION

We investigated the effect of interstitial cystitis (IC) urine on bladder layers and nociceptive centers in the spinal cord with determination of nerve growth factor (NGF), neuronal nitric oxide synthase (nNOS) and c-fos expressions.

MATERIAL AND METHODS

Female rats were instilled into the bladder IC urine (Group-IC), normal urine (Group-NU) and saline (Group-S). NGF, nNOS and c-fos activity were determined in the L6-S1 medulla spinalis with identification of mast cell and NGF activity on bladder layers.

RESULTS

There was more NGF expression cell density in the bladder wall that was determined immunohistochemically in control and IC urine instillation groups than Group-S. While there was no difference in nNOS, NGF and c-fos activity between spinal cord regions except the lateral dorsal horn of the L6 section, localization of activities was different in Group-IC.

CONCLUSIONS

The characteristics of the bladder wall and its nociceptive afferents after human urine instillation of some toxic compounds might be causative factors for IC. However, it is barely hard to conclude that different toxic compounds should be causative factors in IC urine in the pathogenesis of IC.