Extracorporeal pelvic floor magnetic stimulation in children with voiding dysfunction

Effects of repetitive functional magnetic stimulation in the sacral nerve in patients with neurogenic detrusor overactivity after suprasacral spinal cord injury: a study protocol for a randomized controlled trial

BACKGROUND

Neurogenic detrusor overactivity (NDO) is a serious and common complication after spinal cord injury, affecting patients' quality of life seriously. Therefore, we developed this research protocol to evaluate the efficacy of repetitive functional magnetic stimulation (rFMS) in the sacral nerve in patients with neurogenic detrusor overactivity (NDO) after suprasacral spinal cord injury (SCI) and provide more options for rFMS in treating NDO after suprasacral SCI.

METHODS

This study is a single-center, randomized, parallel-group clinical trial. We will recruit the patients with NDO after suprasacral SCI in the Rehabilitation Department of the Affiliated Hospital of Southwest Medical University from September 2022 to August 2023. They will be assigned to the rFMS group and the sham stimulation group randomly. The sample size is 66, with 33 patients in each group. The rFMS group will receive real rFMS treatment of the sacral nerve (100% stimulation intensity, 5 Hz, 20 min each time, five times a week), and the sham group will receive sham stimulation. Both groups will receive similar treatment strategies, including medication, standard urine management, acupuncture treatment, and health education. The bladder compliance (bladder capacity/detrusor pressure) and pudendal nerve electromyography will be evaluated at baseline, 8th week of treatment. The residual volume of the bladder and bladder diary will be recorded once a week during 8 weeks of treatments. SCI-QOL and NBSS will be evaluated at baseline, the 4th and 8th week of treatment. In addition, the above assessments will be followed up at 8 weeks after the end of treatment.

DISCUSSION

It is expected that the bladder function, symptoms, and quality of life might be significantly improved after rFMS of the sacral nerve.

TRIAL REGISTRATION

The China Clinical Trials Registry has approved this study, registration number: ChiCTR2100045148. Registered on April 7, 2021.

Physical Agent-Based Treatments for Overactive Bladder: A Review

Almost one-fifth of the people in the world experience a decrease in quality of life due to overactive bladder (OAB) syndrome. The main bothersome symptoms are urgency accompanied by urinary frequency and nocturia. This chronic, disabling condition is first managed by reducing fluid intake and pelvic floor muscle training, supplemented with antimuscarinic drugs, if necessary. However, refractory cases often still occur. In more severe cases, invasive surgical interventions can be considered; yet, the success rate is still inconsistent, and there is a high complication rate. This condition is frustrating for patients and challenging for the medical staff involved. Although its pathophysiology has not been fully elucidated, peripheral autonomic somatic and sensory afferent receptors are considered to be involved in this condition. Hence, currently, physical agent-based treatments such as neuromodulation have taken a significant place in the third-line therapy of OAB. The efficacy and safety profiles of electrical and magnetic stimulation continue to evolve. Physical-based agents provide an appealing option owing to their effectiveness and minimal side effects. In addition, more physical therapies using light and shock energy are currently being investigated. Thus, a comprehensive understanding of these modalities is an extremely important aspect to provide the most suitable modalities for patients.

Effects of Extracorporeal Magnetic Stimulation in Fecal Incontinence

Background

Fecal incontinence (FI) is a common condition that has devastating consequences for patients’ QOL. In some patients, the conventional functional pelvic floor electrical stimulation has been effective but is an invasive and embarrassing treatment. The object of the study was to evaluate the feasibility of functional extracorporeal magnetic stimulation (FMS) in strengthening the pelvic floor muscles without an anal plug and the embarrassment of undressing.

Materials and Methods

Thirty patients (26 female and 4 males) with FI were enrolled. All patients were assessed during a specialized coloproctology evaluation followed by endoanal ultrasonography and anorectal manometry. All patients underwent an FMS treatment once weekly for 8 weeks. Patients’ outcome was assessed by the Cleveland Clinic Fecal Incontinence Score (CCFIS) and by the fecal incontinence QOL questionnaire (FIQL).

Results

After 8 weeks, the number of solid and liquid stool leakage per week was significantly reduced (p<0.05) with a significant improvement of the CCFIS and of the FIQL (p<0.05). Moreover, the authors recorded a missed recruitment of the agonist and antagonists’ defecation muscles.

Conclusion

FMS is a safe, non-invasive and painless treatment for FI. It could be recommended for selected patients with non-surgical FI to ensure a rapid clinical improvement.

Does sacral pulsed electromagnetic field therapy have a better effect than transcutaneous electrical nerve stimulation in patients with neurogenic overactive bladder?

Objective

To compare the effectiveness of pulsed electromagnetic field therapy (PEMFT) and transcutaneous electrical nerve stimulation (TENS) on neurogenic overactive bladder dysfunction (OAB) in patients with spinal cord injury (SCI).

Patients and methods

In all, 80 patients [50 men and 30 women, with a mean (SD) age of 40.15 (8.76) years] with neurogenic OAB secondary to suprasacral SCI were included. They underwent urodynamic studies (UDS) before and after treatment. Patients were divided into two equal groups: Group A, comprised 40 patients who received 20 min of TENS (10 Hz with a 700 s generated pulse), three times per week for 20 sessions; Group B, comprised 40 patients who received PEMFT (15 Hz with 50% intensity output for 5 s/min for 20 min), three times per week for 20 sessions.

Results

In Group B, there was a significant increase in the maximum cystometric capacity (P < 0.001), volume at first uninhibited detrusor contraction (P < 0.002), and maximum urinary flow rate (P < 0.02).

Conclusion

The UDS showed that the effects of PEMFT in patients with neurogenic OAB secondary to suprasacral SCI was better than TENS for inducing an inhibitory effect on neurogenic detrusor overactivity.

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.

Comparison of biofeedback therapy in children with treatment-refractory dysfunctional voiding and overactive bladder

OBJECTIVE

To evaluate and compare the effectiveness of biofeedback therapy (BF) in children with treatment refractory overactive bladder (OAB) and dysfunctional voiding (DV).

METHODS

This study was performed between April 2012 and March 2014. Patients with treatment refractory OAB and DV were included. All patients had 3 months of BF. Patients' urologic system symptoms and uroflow parameters before BF and 3 months after BF and response rates were compared.

RESULTS

Forty-five patients completed the study. Significant improvement was seen in urinary tract infections, urge incontinence, fractionated voiding, constipation, voided volume, maximum flow rate (Qmax), average flow rate (Qave), and postvoiding residue for patients with DV and in urinary tract infection, frequency, urge incontinence, Qmax, Qave, voiding time, and postvoiding residue for patients with OAB. Overall, better results were observed in patients with DV.

CONCLUSION

BF is an effective treatment modality in children with treatment refractory OAB and DV; however, patients with DV show better improvement.

Evaluation and treatment of nonmonosymptomatic nocturnal enuresis: a standardization document from the International Children's Continence Society

PURPOSE

This document represents the consensus guidelines recommended by the ICCS on how to evaluate and treat children with nonmonosymptomatic nocturnal enuresis (NMNE). The document is intended to be clinically useful in primary, secondary and tertiary care.

MATERIALS AND METHODS

Discussions were held by the board of the ICCS and a committee was appointed to draft this document. The document was then made available to the members of the society on the web site. The comments were vetted and amendments were made as necessary to the document.

RESULTS

The main scope of the document is the treatment of NMNE with drugs other than desmopressin-based therapy. Guidelines on the assessment, and nonpharmacologic and pharmacologic management of children with NMNE are presented.

CONCLUSIONS

The text should be regarded as an expert statement, not a formal systematic review of evidence-based medicine. It so happens that the evidence behind much of what we do in the care of enuretic children is quite weak. We do, however, intend to present what evidence there is, and to give preference to this rather than to experience-based medicine, whenever possible.

Efficacy of High-frequency Magnetic Stimulation of the Sacral Root in Patients with Urinary Incontinence Following a Radical Prostatectomy

OBJECTIVES

We report on our initial data from a prospective study to determine the efficacy of high-frequency magnetic stimulation on the sacral root (MSSR) for the intractable post-radical prostatectomy, stress urinary incontinence (SUI).

METHODS

A total of 14 men with persistent SUI after a radical prostatectomy underwent treatment once every 2 weeks over a 40-week period for a total of 20 sessions. The outcome was assessed by these variables at baseline, at immediately after the first session, and at immediately after the final (20(th) ) session.

RESULTS

Mean leak episodes (per day) consistently decreased after the first to the final session (from 6.1 ± 2.9 to 3.5 ± 2.6, and to 3.0 ± 2.3, P < 0.01), and it remained to be decreased following 2 months after the final session. The mean pad weight (per h) also decreased after the treatment (but no statistically significant change compared to the pretreatment level). The cystometric bladder capacity at the first desire to void and the capacity at the strong desire to void increased significantly following the high-frequency MSSR (first desire to void: from 146 ± 43 to 182 ± 52 mL; strong desire to void: from 224 ± 69 to 258 ± 60 mL, P < 0.01). No obvious complication was observed in any patients during or after the treatment.

CONCLUSION

This study provides the preliminary evidence that high-frequency MSSR may potentially afford a useful option with minimal invasiveness for the patients with obstinate SUI after a radical prostatectomy.

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.

Comparison of alpha-blocker, extracorporeal magnetic stimulation alone and in combination in the management of female bladder outlet obstruction

INTRODUCTION AND HYPOTHESIS

To determine the effects of alpha-blocker, extracorporeal magnetic innervations (ExMI) alone and combination treatment on female bladder outlet obstruction (BOO).

METHODS

Sixty women with BOO were divided into three groups according to the treatment. After 3 months, the clinical outcomes were evaluated by clinical examination, international prostatic symptom score (IPSS), quality of life (QOL), 3-day voiding diary, uroflowmetry and post-void residual.

RESULTS

At 3 months, symptom improvement was 52.6% in alpha-blocker monotherapy (group I), 50.0% in ExMI monotherapy (group II), and 57.1% in combination therapy (group III). Maximum flow rate increased and total IPSS decreased significantly in all groups (p < 0.05). Storage symptom subscore was more reduced in groups II and III and QOL improved significantly in group III (p < 0.05)

CONCLUSIONS

This study demonstrates that both alpha-blocker and ExMI were effective in female BOO, and ExMI may be more effective for improving storage symptoms.

Extracorporeal magnetic innervation therapy in children with refractory monosymptomatic nocturnal enuresis

OBJECTIVES

To evaluate the effect of extracorporeal magnetic innervation (ExMI) therapy in children with refractory monosymptomatic nocturnal enuresis (MNE).

METHODS

A total of 55 children (34 boys and 21 girls, median age 8.0 years, range 5 to 13) who wetted the bed more than twice per week because of MNE that was refractory to treatment with desmopressin, anticholinergics, and enuretic alarm were assessed prospectively using a voiding diary before and after ExMI, administered once a week for at least 4 weeks with a size-adjusted magnetic chair (each session lasted 20 minutes).

RESULTS

After all sessions of ExMI, the mean frequency of nocturnal enuresis decreased significantly to 2.09 +/- 2.47 in all patients (P = 0.04), and the mean functional bladder capacity increased 1.88 times in all patients (P = 0.00). In total, 63.6% of our patients had a nocturnal enuresis frequency of less than 50% after a mean of 6.62 +/- 4.26 ExMI sessions.

CONCLUSIONS

From our results, reduced functional bladder capacity might be the main pathophysiologic cause in children with MNE refractory to established treatment. ExMI might have an acute inhibitory effect in these children with refractory MNE by increasing functional bladder capacity. However, long-term follow-up data and controlled study with a sham-stimulation group are necessary to determine the durability of this new therapy for refractory MNE.

Topographic anatomy of a new posterior approach to the pudendal nerve for stimulation

OBJECTIVES

To describe a new approach to the pudendal nerve from a dorsal direction in terms of topographic anatomy and to discuss pudendal nerve neurophysiology in light of the rationale behind pudendal nerve stimulation to treat lower urinary tract disorders.

MATERIALS AND METHODS

Cadavers of four women aged 78-87 yr were studied. After placing the cadavers in prone position with a 40 degrees -60 degrees flexion of the hips and determining anatomic landmarks, a 20-G insulated needle was inserted close to the pudendal nerve. Then the topographic relationships of the puncture with the pudendal canal were explored by dissection.

RESULTS

The mean points of insertion of the needle were 14 cm inside the great trochanter, 9 cm above the ischiatic tuberosity, and 6 cm outside the gluteal fold. If the needle was inserted 6.5 cm under the previous with an orifice of 60 degrees and this route was followed, the needle could have a contact area with the pudendal nerve larger, leading to a greater stimulation efficacy with less stimulation intensities. The rectum was so far away that a rectal injury with the needle seemed unlikely. No vascular structure was at the contact of the nerve.

CONCLUSIONS

The described new puncture technique to reach the pudendal nerve provides easy and safe accessibility of the nerve for stimulation. In light of our increasing understanding of the rationale behind neuromodulative stimulation, the pudendal nerve could be a promising target for continuous lower urinary tract neuromodulation by implant.

Biofeedback therapy in the treatment of bladder overactivity, vesico-ureteral reflux and urinary tract infection

OBJECTIVE

Voiding disorders are commonly encountered in paediatric urology practice. Urinary incontinence often leads to the impairment of self-esteem but can also cause renal damage, when recurrent urinary tract infection (UTI) or vesico-ureteral reflux (VUR) exists. The aim of this study was to assess the efficacy of a biofeedback training program in children with a long history of voiding disorders.

PATIENTS AND METHODS

Between 1998 and 2002, 60 children with voiding disorders without neuropathic disease, aged 5-14, were treated. There were 48 girls and 12 boys. The main symptoms were daytime incontinence for 90%, urge syndrome for 78%, and night-time incontinence for 60%. UTIs were noted in 62% of the children, for 37% of them in association with a VUR. Ten weekly sessions were planned for all the children. They were given instructions on toilet behaviour and posture, and pelvic floor training. They had to supervise their voiding frequency and liquid intake at home using a chart. Biofeedback procedure used surface perineal electrodes. The exercises focused on relaxation of the perineum.

RESULTS

The first results were recorded 6 months after the last session: 96% of the children with daytime incontinence and 83% of the children with night-time incontinence were cured or improved; 84% of the children were free from infection and VUR was cured in 50% of cases. After a mean follow-up of 21 months, 8% of the children with daytime incontinence and 33% with night-time incontinence relapsed, with a significant difference between primary and secondary enuresis. A breakthrough UTI was observed in 19% of cases.

CONCLUSION

This non-invasive training program was effective in the treatment of daytime incontinence, UTI and VUR. There was an improvement in secondary but not primary enuresis. To prevent relapse, additional support sessions seem to be necessary.