Effects of posterior tibial nerve stimulation (PTNS) on lower urinary tract dysfunction: An umbrella review

BACKGROUND

Lower urinary tract dysfunction (LUTD) is a common, troublesome condition that often negatively affects patients' quality of life. Current literature has long been interested in how posterior tibial nerve stimulation (PTNS) can affect this condition.

AIM

To extensively and systematically explore how PTNS affects LUTD based on the most recent systematic reviews.

METHODS

A systematic search was conducted in PubMed, Scopus, Web of Science, and Embase according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. All the systematic reviews, with or without meta-analysis that assessed the effects of PTNS on LUTD were retrieved. The quality of the included studies was assessed using the Joanna Briggs Institute tool, and analysis was conducted using the Comprehensive Meta-Analysis version 3 tool.

RESULTS

From a total of 3077 citations, 20 systematic reviews entered this study, and 13 of them included meta-analysis. The population of studies varied vastly, for instance, some studies included only children or women while other focused on a specific pathology like multiple sclerosis-induced neurogenic LUTD. The majority of included studies reported an overall improvement in LUTD following percutaneous PTNS, although admitting that these results were derived from moderate to low-quality evidence.

CONCLUSION

The findings of this thorough umbrella review showed that the positive benefits of PTNS in treating LUTD are currently supported by low-quality evidence, and it is crucial to interpret them with great care.

Response to tibial and sacral nerve modulation in overactive bladder: Is there any correlation?

OBJECTIVES

To assess the correlation between the response to transcutaneous tibial nerve stimulation (TTNS) and subsequent response to sacral nerve modulation (SNM) to treat overactive bladder (OAB).

MATERIALS AND METHODS

All patients who consecutively received TTNS followed by a two-stage SNM between January 2016 and June 2022 to treat OAB in two university hospital centers were included. The response to each therapy was evaluated with success defined by a 50% or greater improvement in one or more bothersome urinary symptoms from baseline. The primary endpoint was the statistical relationship between the response to TTNS and the response to SNM, assessed by logistic regression. Secondary endpoints were the statistical relationship between the response to TTNS and the response to SNM when controlling for gender, age (<57 years vs. >57 years), presence of an underlying neurological disease, and presence of DO, adding the factor and interaction to the previous regression model.

RESULTS

Among the 92 patients enrolled in the study, 68 of them were women (73.9%), and the median age was 57.0 [41.0-69.0] years. The success was reported in 22 patients (23.9%) under TTNS and 66 patients (71.7%) during the SNM test phase. There was no statistical correlation between response to TTNS and response to SNM in the overall population (confidence interval: 95% [0.48-4.47], p = 0.51). Similarly, there was no statistical correlation when controlling for age <57 years or ≥57 years, with p = 1.0 and p = 0.69, respectively. No statistical study could be conducted for the other subpopulations due to small sample sizes.

CONCLUSION

The response to TTNS does not predict the response to SNM in the treatment of OAB. TTNS and SNM should be considered as separate therapies, and the decision-making process for OAB treatment should take this into account.

bTUNED: transcutaneous tibial nerve stimulation for neurogenic lower urinary tract dysfunction

OBJECTIVE

To present the protocol for a randomized controlled trial (RCT) evaluating the efficacy and safety of transcutaneous tibial nerve stimulation (TTNS) for refractory neurogenic lower urinary tract dysfunction (NLUTD).

STUDY DESIGN AND RESULTS

bTUNED (bladder and TranscUtaneous tibial Nerve stimulation for nEurogenic lower urinary tract Dysfunction) is an international multicentre, sham-controlled, double-blind RCT investigating the efficacy and safety of TTNS. The primary outcome is success of TTNS, defined as improvements in key bladder diary variables at study end compared to baseline values. The focus of the treatment is defined by the Self-Assessment Goal Achievement (SAGA) questionnaire. Secondary outcomes are the effect of TTNS on urodynamic, neurophysiological, and bowel function outcome measures, as well as the safety of TTNS.

CONCLUSIONS

A total of 240 patients with refractory NLUTD will be included and randomized 1:1 into the verum or sham TTNS group from March 2020 until August 2026. TTNS will be performed twice a week for 30 min during 6 weeks. The patients will attend baseline assessments, 12 treatment visits and follow-up assessments at the study end.

Development of a Sham Protocol to Investigate Transcutaneous Tibial Nerve Stimulation in Randomised, Sham-Controlled, Double-Blind Clinical Trials

Transcutaneous tibial nerve stimulation (TTNS) is a promising treatment for neurogenic lower urinary tract symptoms. However, the evidence is limited due to a general lack of randomised controlled trials (RCTs) and, also, inconsistency in the sham and blinding conditions. In the context of much-needed RCTs, we aimed to develop a suitable sham-control protocol for a clinical setting to maintain blinding but avoid meaningful stimulation of the tibial nerve. Three potential electrode positions (lateral malleolus/5th metatarsal/plantar calcaneus) and two electrode sizes (diameter: 2.5 cm/3.2 cm) were tested to determine which combination provided the optimal sham configuration for a TTNS approach, based on a visible motor response. Sixteen healthy volunteers underwent sensory and motor assessments for each sham configuration. Eight out of them came back for an extra TTNS visit. Sensory thresholds were present for all sham configurations, with linear regression models revealing a significant effect regarding electrode position (highest at plantar calcaneus) but not size. In addition, motor thresholds varied with the position-lowest for the 5th metatarsal. Only using this position and 3.2 cm electrodes attained a 100% response rate. Compared to TTNS, sensory and motor thresholds were generally higher for the sham configurations; meanwhile, perceived pain was only higher at the lateral malleolus. In conclusion, using the 5th metatarsal position and 3.2 cm electrodes proved to be the most suitable sham configuration. Implemented as a four-electrode setup with standardized procedures, this appears to be a suitable RCT protocol for maintaining blinding and controlling for nonspecific TTNS effects in a clinical setting.

The effectiveness and safety of oral medications, onabotulinumtoxinA (three doses) and transcutaneous tibial nerve stimulation as non or minimally invasive treatment for the management of neurogenic detrusor overactivity in adults: a systematic review and network meta-analysis

BACKGROUND

Oral medications, onabotulinumtoxinA injections, and transcutaneous tibial nerve stimulation (TTNS) are recommended by the American Urological Association/Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction guidelines as non or minimally invasive treatments for patients with neurogenic detrusor overactivity (NDO) without treatment hierarchy.

OBJECTIVE

The objective was to compare and rank the effectiveness and safety of oral medications, three doses of onabotulinumtoxinA, and TTNS on improving urodynamic outcomes in patient-reported outcomes and safety outcomes in patients with NDO.

METHODS

The authors searched PubMed, EMBASE, MEDLINE, Cochrane Library, Medicine, and clinicaltrials.gov, from their inception to October 2022 and included randomized controlled studies on the drug, onabotulinumtoxinA, and TTNS for the treatment of patients with NDO. Outcomes included urodynamic parameters, voiding diary, quality of life changes, adverse event rate and postvoid residual.

RESULTS

A total of 26 articles and 2938 patients were included in the statistics. Regarding effectiveness, all interventions except TTNS and α-blockers were statistically different for the placebo group. The urodynamic outcome and patient-reported outcome suggested that onabotulinumtoxinA injection (urodynamic outcome: onabotulinumtoxinA 200 U, the mean surface under the cumulative ranking curve (SUCRA): 87.4; patient-reported outcome: onabotulinumtoxinA 100 U, mean SUCRA: 89.8) was the most effective treatment, and the safety outcome suggested that TTNS (SUCRA: 83.3) was the safest. Cluster analysis found that antimuscarinics and β3-adrenoceptor-agonists possessed good effectiveness and safety.

CONCLUSION

OnabotulinumtoxinA injection is probably the most effective way to treat patients with NDO, with increasing effectiveness but decreasing safety as the dose rises. The effectiveness of α-blockers and TTNS was not statistically different from the placebo group. Antimuscarinics and β3-adrenoceptor-agonists have good effectiveness and safety.

Comparison of transcutaneous tibial nerve stimulation versus percutaneous tibial nerve stimulation in category IIIB chronic prostatitis/chronic pelvic pain syndrome: A randomized prospective trial

BACKGROUND

Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is a heterogenous condition that impacts the Quality of life severely, and it has multimodal complex treatment options. We aimed to compare the efficacy of two well-described neuromodulation therapies, transcutaneous tibial nerve stimulation (TTNS) versus percutaneous tibial nerve stimulation (PTNS) in the treatment of category IIIB CP/CPPS.

METHODS

This study was designed as a randomized prospective clinical trial. We randomized category IIIB CP/CPPS patients into two treatment groups as TTNS and PTNS groups. Category IIIB CP/CPPS was diagnosed by two or four-glass Meares-Stamey test. All patients included in our study were antibiotic/anti-inflammatory resistant. Transcutaneous and percutaneous treatments were applied 30 min sessions for 12 weeks. Patients were evaluated by Turkish-validated National Health Institute Chronic Prostatitis Symptom Index (NIH-CPSI) and visual analogue scale (VAS) initially and after treatment. Treatment success was evaluated within each group and also compared with each other.

RESULTS

A total of 38 patients in the TTNS group and 42 patients in the PTNS group were included in the final analysis. The mean VAS scores of the TTNS group were lower than the PTNS group initially (7.11 and 7.43, respectively), (p = 0.03). The pretreatment NIH-CPSI scores were similar between groups (p = 0.07). VAS scores, total NIH-CPSI, NIH-CPSI micturation, NIH-CPSI pain, and NIH-CPSI QoL scores decreased significantly at the end of the treatment in both groups. We found a significantly higher VAS and NIH-CPSI scores decrease in the PTNS group compared to the TTNS group (p < 0.01).

CONCLUSION

Both PTNS and TTNS are effective treatment methods in category IIIB CP/CPPS. Comparing the two methods, PTNS provided a higher level of improvement in terms of pain and quality of life.

Efficacy of Transcutaneous Tibial Nerve Stimulation With Silver Spike Point® Electrodes for Refractory Overactive Bladder: A Single-Arm Study

Background Tibial nerve stimulation therapy is a treatment option for an overactive bladder. A surface electrode called a Silver Spike Point® electrode, which does not directly puncture the skin as in transcutaneous tibial nerve stimulation, but is expected to exert the same therapeutic effect as percutaneous tibial nerve stimulation, was developed. This study investigated the efficacy and safety of tibial nerve stimulation with Silver Spike Point® electrodes for refractory overactive bladder. Methodology This was a six-week, single-arm, prospective study on the efficacy and safety of transcutaneous tibial nerve stimulation for patients with refractory overactive bladder. Each treatment lasted 30 minutes and was performed twice a week. The stimulation sites of the tibial nerve were the Sanyinjiao point (SP6) and Zhaohai point (KI6) in both legs. The primary endpoint was the change in the total overactive bladder symptom score. Results In total, 29 patients (20 males and nine females: 64.86 ± 17.98 years old) were included in this study. Two women dropped out; one because of an adverse event and the other as requested. Therefore, 27 patients completed the study. The total overactive bladder symptom and International Consultation on Incontinence Questionnaire-Short Form scores significantly decreased by 2.22 and 2.39 points, respectively (p < 0.01 each). In the frequency volume chart, the numbers of urgency episodes and leaks in 24 hours significantly decreased by 1.53 and 0.44, respectively (p = 0.02 each). Conclusions Transcutaneous tibial nerve stimulation therapy using Silver Spike Point® electrodes was useful for patients with refractory overactive bladder and, thus, has potential as a new treatment option for refractory overactive bladder.

Non-inferior and more feasible transcutaneous tibial nerve stimulation in treating overactive bladder: A systematic review and meta-analysis

OBJECTIVES

Overactive bladder (OAB) is identified as a urinary urgency accompanied by frequency and nocturia with or without urgency urinary incontinence in the nonexistence of a urinary tract infection or other evident pathologies. This systematic review and meta-analysis aimed to evaluate the efficacy of the transcutaneous tibial nerve stimulation (TTNS) versus percutaneous tibial nerve stimulation (PTNS) or anticholinergic drugs in reducing symptoms and improving the quality of life for OAB patients.

METHODS

We performed a systematic search in Medline, Embase, and CENTRAL, in which we included randomized controlled trials that compared TTNS with anticholinergic drugs or PTNS in treating idiopathic OAB. We evaluated the following outcomes: 3-day voiding diary (voiding frequency/day, daytime micturition frequency/day, nighttime micturition frequency/day, number of urgency episodes/day, number of incontinence episodes/day, and mean voiding volume), symptom bother, health related quality of life (HRQoL), and adverse events. We used 95% as a confidence interval (CI) and p < 0.05. Standardized mean difference (SMD) was used for continuous outcomes, and the risk ratio (RR) was used for dichotomous outcomes.

RESULTS

There was no significant difference comparing TTNS with anticholinergic drugs or PTNS regarding voiding frequency/day (SMD = -0.01, 95% CI -0.33 to 0.32), nighttime micturition frequency/day (SMD = -0.28, 95% CI -0.94 to 0.37), number of urgency episodes/day (SMD = -0.05, 95% CI -0.36 to 0.26), number of incontinence episodes/day (SMD = -0.04, 95% CI -0.32 to 0.25), symptom bother (SMD = -0.19, 95% CI -0.55 to 0.16), HRQoL (SMD = 0.27, 95% CI -0.32 to 0.85), and adverse events (RR = 0.07, 95% CI 0.01 to 0.54).

CONCLUSION

The current meta-analysis reveals that there is no statistically significant difference between TTNS versus PTNS or anticholinergic drugs for the nonsurgical management of OAB patients.

Evaluating the effects of transcutaneous tibial nerve stimulation or pelvic floor muscle training on sexual dysfunction in female multiple sclerosis patients reporting overactive bladder

AIMS

Sexual dysfunction (SD) is common in female patients with multiple sclerosis (MS) reporting overactive bladder (OAB) symptoms. The aim of the study was to evaluate the effects of transcutaneous tibial nerve stimulation (TTNS) and pelvic floor muscle training (PFMT) with biofeedback on SD in female patients with MS reporting OAB symptoms.

METHODS

Patients with overactive bladder and SD were allocated to receive TTNS or PFMT daily. Overactive bladder symptoms, sexual functions, and sexual quality of life were assessed at baseline and 6^th weeks. Female Sexual Function Index (FSFI), Overactive Bladder Questionnaire (OABv-8), and Sexual Quality of Life-Female (SQoL-F) questionnaires were used.

RESULTS

Thirty patients (TTNS = 10, PFMT = 20) were included in the study. Compared to baseline, total FSFIOABv-8, and SQoL-F scores improved in both TTNS (p = 0.005, p = 0.011, p = 0.444, respectively) and PFMT (p = 0.002, p = 0.001, p = 0.001, respectively) groups. Between-group comparisons did not show any significant differences.

CONCLUSION

This study demonstrates the efficacy of both TTNS and PFMT for improving sexual function in female MS patients with OAB symptoms, but did not show superiority of any particular method. Further studies are required to investigate the differences between these two non-invasive methods.

Treatment for overactive bladder: A meta-analysis of transcutaneous tibial nerve stimulation versus percutaneous tibial nerve stimulation

BACKGROUND

We aim to compare the safety and effectiveness of transcutaneous tibial nerve stimulation (TTNS) versus percutaneous tibial nerve stimulation (PTNS) in treating overactive bladder.

METHODS

A systematical search on PubMed, Embase, clinicalTrial.gov, and Cochrane Library Central Register of Controlled Trials from January 1, 1999 to November 1, 2020 was performed. The primary outcomes were the changes in a 3-day voiding diary. Quality of life scores were also evaluated. Review Manager 5.3 (Cochrane Collaboration, Oxford, UK) was applied to conduct all statistical analyses.

RESULTS

A total of 4 trials (2 randomized controlled trials, 1 retrospective study, and 1 before-after study) with 142 patients were eventually enrolled. Compared with PTNS, TTNS had a similar performance in the voiding frequency in 24 hours (mean difference [MD] = -0.65, 95% confidence interval [CI]: -1.35 to 0.05, P = .07), the number of urgency episodes in 24 hours (MD = 0.13, 95% CI: -0.36 to 0.62, P = .60), the number of incontinence episodes in 24 hours (MD = 0.01, 95% CI: -0.13 to 0.14, P = .93), as well as in the nocturia frequency (MD = -0.14, 95% CI: -0.52 to 0.24, P = .47). Moreover, comparable results were observed regarding HRQL scores (P = .23) and incontinence quality of life scores (P = .10) in both groups. The total complication rate in the current study was 2.1% (3/142). No adverse events were identified in the TTNS group.

CONCLUSION

Current data supported that TTNS is as effective as PTNS for the treatment of overactive bladder, moreover, with no reported adverse events. However, the evidence is low-grade and well-designed prospective studies with a large sample size are warranted to verify our findings.

Efficacy of percutaneous and transcutaneous tibial nerve stimulation in women with idiopathic overactive bladder: A prospective randomised controlled trial

BACKGROUND

Different studies have reported the efficacy of percutaneous tibial nerve stimulation (PTNS) and transcutaneous tibial nerve stimulation (TTNS) in treating idiopathic overactive bladder (OAB). However, no study has compared the effectiveness of PTNS and TTNS added to bladder training (BT) in idiopathic OAB.

OBJECTIVE

To compare the efficacy of PTNS and TTNS added to BT in women with idiopathic OAB.

METHODS

We randomised 60 women with idiopathic OAB into 3 groups. Group 1 (n=19) received BT, Group 2 (n=19) received PTNS in addition to BT, and Group 3 (n=20) received TTNS in addition to BT. PTNS and TTNS were performed 2 days a week, for 30 min a day, for a total of 12 sessions for 6 weeks. Patients were evaluated by incontinence severity (pad test), a 3-day voiding diary (frequency of voiding, incontinence episodes, nocturia and number of pads used), symptom severity, quality of life, treatment success (positive response rate), treatment satisfaction (Likert scale), discomfort level and preparation time for stimulation (sec).

RESULTS

At the end of treatment; severity of incontinence, frequency of voiding, incontinence episodes, nocturia, number of pads used, symptom severity and quality of life were significantly improved in Groups 2 and 3 versus Group 1 (p<0.0167). Treatment success and treatment satisfaction were higher in Groups 2 and 3 than Group 1 (p<0.001 and p<0.0167, respectively). Level of discomfort was lower, treatment satisfaction was higher and preparation time for stimulation was shorter in Group 3 than Group 2 (p<0.05).

CONCLUSION

Both the PTNS plus BT and TTNS plus BT were more effective than BT alone in women with idiopathic OAB. These 2 tibial nerve stimulation methods had similar clinical efficacy but with slight differences: TTNS had shorter preparation time, less discomfort level and higher patient satisfaction than PTNS.

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).

Patient-reported outcomes in the setting of a randomized control trial on the efficacy of transcutaneous stimulation of the posterior tibial nerve compared to percutaneous stimulation in idiopathic overactive bladder syndrome

AIM

To compare the efficacy of transcutaneous tibial nerve stimulation (TTNS) with percutaneous tibial nerve stimulation (PTNS) regarding patient-reported outcomes measures, specifically quality-of-life (QoL) improvement and patient's treatment benefit, on symptoms associated with overactive bladder (OAB).

METHODS

Patients with refractory OAB symptoms and detrusor overactivity were randomized to receive TTNS or PTNS for 12 weeks. Data from self-report OAB questionnaire short form (q-SF) and incontinence (I)-QoL questionnaires were collected pretreatment and at Weeks 6 and 12. Patients' self-perceived benefits on symptoms (treatment benefit scale, TBS) were also gathered. Mean change in scores within and between groups were estimated.

RESULTS

Sixty-eight adult patients (67.6% women) were included in the intention to treat analysis. Of those, 61 completed all questionnaires and were analyzed as per protocol. Statistically significant improvements in OAB-q-SF and I-QoL between baseline and end-of-treatment scores were observed in both TTNS and PTNS groups (p < .001), being the differences much higher than the minimal important difference in both questionnaires. The scores of the OAB-q-SF scales (symptoms bother and health-related QoL) showed no statistically significant differences between the two groups. Similarly, the differences regarding the I-QoL questionnaire were statistically nonsignificant either (p = .607). When assessing the treatment benefit on symptoms, TBS responses between groups showed no statistical differences.

CONCLUSION

A significant improvement of QoL was observed in both TTNS and PTNS groups. However, no patient-reported outcomes measures scores support a difference between the two groups. Therefore, these findings along with TTNS ease of application and less invasiveness may lead to an increased indication of this technique for OAB.

Interventions and cognitive functioning in adults with traumatic spinal cord injuries: a systematic review and meta-analysis

AIM

This research synthesized scientific evidence on the impact of interventions for adults with traumatic spinal cord injury on cognition, to understand if current intervention approaches are appropriate in light of the risk of post-injury cognitive impairments.

METHOD

Medline, Central, Embase, Scopus, PsycINFO and PubMed were searched for intervention in persons with SCI assessing cognition pre- and post-intervention. Study quality was completed using the National Institutes of Health quality assessment tools. Results were grouped by type of intervention. The meta-analysis involved calculation of pooled effect sizes for interventions utilizing the same cognitive measure.

RESULTS

Eleven studies of moderate quality discussed drug therapy, transcutaneous tibial nerve stimulation, diet modification and dietary supplements, and inpatient rehabilitation. Some aspects of cognition were negatively affected by drugs while diet modification and supplement use, and transcutaneous tibial nerve stimulation showed no evidence of a difference in cognitive scores when compared with no intervention. Inpatient rehabilitation revealed a small but beneficial effect, when results of seven studies were pooled.

CONCLUSION

Evidence on the effects of interventions on cognitive functioning in patients with traumatic spinal cord injury is sparse and inconclusive, so work in this area is timely. It is valuable to know not only which interventions are effective for improving cognition, but also how other commonly used interventions, intended to treat other injury sequela, can affect cognition. PROSPERO: CRD42018087238.Implications for rehabilitationHistorically, rehabilitation of patients with traumatic spinal cord injury has targeted physical impairments, with little attention to cognition; this research aimed to understand if current interventions are appropriate in light of the risk of patients' cognitive impairments. Evidence on the effects of drug therapy, diet and dietary supplements interventions on cognitive functioning in traumatic spinal cord injury is sparse and inconclusive.Combining multiple inpatient rehabilitation interventions shows a positive but heterogeneous effect on the cognitive functioning; interventions applied earlier show greater gains.A major challenge for clinicians is to select an outcome measure sensitive to change over time, and to relate the results to patients' change in cognitive abilities with intervention applicationResearch to understand the functional effect of spinal cord injury on the widely distributed networks of the central and autonomic nervous systems subserving cognition, is timely.