Transcutaneous electrical posterior tibial nerve stimulation for faecal incontinence: effects on symptoms and quality of life

Purpose  

Faecal incontinence is a disabling symptom which may be particularly difficult to treat. Recent studies showed that transcutaneous electrical posterior tibial nerve stimulation may improve faecal continence. In this study, we aimed to evaluate the effectiveness of this technique and tried to individualize predictive factors of success.     

Transcutaneous electrical posterior tibial nerve stimulation for chronic anal fissure: a preliminary study

Purpose

Recent studies showed that sacral nerve stimulation might be an effective treatment option for chronic anal fissure. We aimed to evaluate the efficacy of transcutaneous electrical nerve stimulation as a noninvasive alternative treatment for chronic anal fissure by stimulating the sacral nerve in the ankle via the posterior tibial nerve.

Method

In this prospective study, transcutaneous electrical nerve stimulation was applied for 10 days in addition to conventional medical treatment in ten patients. Wexner's constipation score, visual analog scale for pain, quality of life (Short Form-36), Hamilton anxiety and depression scores, symptom relief, compliance, fissure healing, and side effects were evaluated before and after treatment (days 0, 5, and 10).

Results

Ten patients (eight females/two males) with a mean age of 50.7?±?18.5 years were enrolled in the study. Pain and bleeding resolved in all patients 2 days after the treatment, and mucosal healing was observed in six patients 10 days after the treatment. Wexner's constipation and visual analog scale scores for pain decreased significantly (p?=?0.001 and p?=?0.002, respectively). Hamilton anxiety and depression scores decreased as well (p?=?0.001 and p?=?0.01, respectively). Among Short Form-36 subscales, only mental health score increased significantly (p?=?0.003). One patient underwent surgery at follow-up due to recurrence of symptoms, and rubber band ligation was applied to another patient who had internal hemorrhoidal rectal bleeding at the end of 10 days.

Conclusions

Transcutaneous electrical nerve stimulation application to the posterior tibial nerve has the potential to be an alternative treatment option for chronic anal fissure patients who seek noninvasive treatment modality.     

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.     

Sacral nerve stimulation versus percutaneous tibial nerve stimulation for faecal incontinence: a systematic review and meta-analysis

Aims

Percutaneous tibial nerve stimulation (PTNS) and sacral nerve stimulation (SNS) are both second-line treatments for faecal incontinence (FI). To compare the clinical outcomes and effectiveness of SNS versus PTNS for treating FI in adults.

Method

A literature search of MEDLINE, Embase, Science Citation Index Expanded and Cochrane was performed in order to identify studies comparing SNS and PTNS for treating FI. A risk of bias assessment was performed using The Cochrane Collaboration’s risk of bias tool. A random effects model was used for the meta-analysis.

Results

Four studies (one randomised controlled trial and three nonrandomised prospective studies) reported on 302 patients: 109 underwent SNS and 193 underwent PTNS. All included studies noted an improvement in symptoms after treatment, without any significant difference in efficacy between SNS and PTNS. Meta-analysis demonstrated that the Wexner score improved significantly with SNS compared to PTNS (weighted mean difference 2.27; 95% confidence interval 3.42, 1.12; P?<?0.01). Moreover, SNS was also associated with a significant reduction in FI episodes per week and a greater improvement in the Fecal Incontinence Quality of Life coping and depression domains, compared to PTNS on short-term follow-up. Only two studies reported on adverse events, reporting no serious adverse events with neither SNS nor PTNS.

Conclusion

Current evidence suggests that SNS results in significantly improved functional outcomes and quality of life compared to PTNS. No serious adverse events were identified with either treatment. Further, high-quality, multi-centre randomised controlled trials with standardised outcome measures and long-term follow-up are required in this field.

     

Chronic posterior tibial nerve transcutaneous electrical nerve stimulation (TENS) to treat fecal incontinence (FI)

Aim  

Transcutaneous electrical nerve stimulation (TENS) is a possible alternative to sacral nerve stimulation because the neurophysiologic targets might be similar but the former method is non-invasive and cheaper. The aim of the study was to assess both symptom and quality of life (QoL) improvements in patients suffering from severe FI.     

Posterior tibial nerve stimulation for faecal incontinence after partial spinal injury: preliminary report

Background This study evaluated the possible effects of posterior tibial nerve stimulation in two patients with faecal incontinence due to partial spinal cord injury. Methods Posterior tibial nerve stimulation was performed for 30 min, every other day for 4 weeks, and was then repeated every 2 months for three months. Clinical examination, anorectal physiological work-up, faecal incontinence severity index, and quality of life assessments were performed before and after the treatment. Results After posterior tibial nerve stimulation, patients showed improvement in rectal sensory threshold, pudendal nerve terminal motor latency, Wexner faecal incontinence score, faecal incontinence severity index, faecal incontinence quality of life scales, resting pressure, and maximum squeeze pressure measurements. Conclusions Posterior tibial nerve stimulation can be an effective method for the treatment of faecal incontinence caused by partial spinal cord injury.     

Sacral nerve stimulation for faecal incontinence due to systemic sclerosis

BACKGROUND: Faecal incontinence occurs in over one third of patients with systemic sclerosis. The aetiology is multifactorial. Conventional treatment is often unsuccessful. Sacral nerve stimulation is a new effective treatment for resistant faecal incontinence. AIMS: To evaluate sacral nerve stimulation in patients with systemic sclerosis. PATIENTS: Five women, median age 61 years (30-71), with scleroderma associated faecal incontinence were evaluated. All had failed maximal conventional treatment. Median number of preoperative weekly episodes of incontinence was 15 (7-25), median duration of incontinence was five years (5-9), and scleroderma 13 years (4-29). METHODS: All patients were screened with temporary stimulation. Those who benefited underwent permanent implantation. At baseline and after stimulation a bowel diary, the SF-36 quality of life assessment, endoanal ultrasound, and anorectal physiology were performed. RESULTS: Four patients were continent at a median follow up of 24 months (6-60). One patient failed temporary stimulation and was not permanently implanted. The weekly episodes of incontinence decreased from 15, 11, 23, and 7 to 0. Urgency resolved (median time to defer <1 minute (0-1) v 12.5 minutes (5-15)). Quality of life, especially social function, improved. Endoanal ultrasound showed an atrophic internal anal sphincter (median width 1.0 mm (0-1.6)). Anorectal physiology showed an increase in median resting pressure (37 pre v 65 cm H(2)O post) and squeeze pressure (89 v 105 cm H(2)O). Stimulation produced enhanced rectal sensitivity to distension. There were no major complications. CONCLUSIONS: Sacral nerve stimulation is a safe and effective treatment for resistant faecal incontinence secondary to scleroderma. The benefit is maintained in the medium term.     

The effects of low-frequency endo-anal electrical stimulation on faecal incontinence: a prospective study

Background and aims Faecal incontinence is a distressing problem that is often not amenable to surgical correction. Chronic low-frequency electrical stimulation of damaged axons is thought to reduce synaptic resistance, increase the size of motor units by axonal sprouting and increase the rate of conduction of the pudendal nerve. The aim of this study was to prospectively evaluate the effect of chronic low-frequency endo-anal electrical stimulation on faecal incontinence using a home-based unit and hospital-supervised therapy.Materials and methods Forty-eight patients with faecal incontinence completed a prospective randomised trial. Patients were allocated randomly to one of two groups; group 1 was exposed to endo-anal pudendal nerve stimulation daily at home with a portable home unit, group 2 attended the physiotherapy department for endo-anal electrical stimulation under supervision.Results Continence scores improved significantly after treatment in both groups (p<0.001). Both groups showed improved manometric scores, although only group 1 showed significant improvement in both resting and squeeze pressures (mean total resting pressure 184–224 mmHg, p<0.001; mean total squeeze pressure 253–337 mmHg, p<0.001). This was also reflected by an improvement in quality of life in both groups.Conclusions Low-frequency endo-anal electrical stimulation significantly improves continence scores and quality of life in patients with faecal incontinence not amenable to surgical correction. It leads to improved manometric values when carried out on a daily basis with a portable home unit.     

Long-term efficacy of percutaneous tibial nerve stimulation for faecal incontinence and a new approach for partial responders

Background

The aim of the present study was to evaluate the long-term efficacy of percutaneous tibial nerve stimulation (PTNS) for patients with faecal incontinence (FI) refractory to conservative treatment. Secondary aims were to identify predictors of response and validate new treatment pathways for partial responders.

Methods

A prospective, interventional study was carried out in a specialist defecatory disorder unit from a university hospital between January 2010 and June 2017 on patients > 18 years old with FI refractory to conservative treatment. Thirty-minute PTNS sessions were performed in three phases (weekly, biweekly and monthly) up to a year, with clinical reassessment at 3, 6, 12 and 36 months.

Patients were classified as optimal responders when their pretreatment Wexner score decreased > 50%; partial responders when it decreased 25–50%; and insufficient responders if it decreased < 25%. Only optimal and partial responders progressed into successive phases.

Results

Between 2010 and 2017, 139 patients (110 women, median age 63 years [range 22–82 years]) were recruited. After the first phase, 4 patients were optimal responders, 93 were partial responders and 36 were insufficient responders. At 6 and 12 months, 66 and 89 patients respectively were optimal responders, with an optimal response rate of 64% at the end of treatment. A total of 93.3% patients with a partial response initially finally became optimal responders. Furthermore, at 36 months, 71.9% of patients were still optimal responders without supplementary treatment, although their quality of life did not improve significantly. Baseline Wexner scores ≤ 10 and symptom duration < 1 year were identified as predictive factors for positive responses to PTNS.

Conclusions

Patients undergoing PTNS for 1 year following this protocol had optimal long-term responses. PTNS sessions for up to 1 year in patients who were partial responders prevents a high percentage of them from needing more invasive treatments, and maintains long-term continence in patients who were optimal responders.

     

Efficacy of cyclic sacral nerve stimulation for faecal incontinence

Background

Sacral nerve stimulation (SNS) is an established treatment option for faecal incontinence. Cyclic stimulation will improve the longevity of the implanted stimulator, but little is known about its efficacy. The aim of this retrospective clinical study was to assess the efficacy of cyclic SNS for faecal incontinence.

Methods

Sixty-three patients underwent percutaneous nerve evaluation (PNE) test with a 2-week period of continuous SNS. The PNE test was deemed positive in 42 patients (67 %) who underwent implantation with permanent stimulator. All 42 patients were initially stimulated in a cyclic manner with stimulation for 20 s followed by 8 s without. During follow-up, the stimulator was explanted in 2 patients and permanently turned off in one due to the loss of effect. A postal questionnaire including the Wexner score, a general quality of life (Qol) score, and a bowel habit diary was distributed to 39 patients.

Results

The questionnaire was returned by 29/39 (74 %) of the patients. Median duration of follow-up was 16 (range 3–34) months. The Wexner score and the general QoL score were significantly improved compared to pre-treatment values. Some 18 patients (62 %) were still treated with cyclic stimulation at follow-up, reporting more frequent episodes of urgency without incontinence (p = 0.020) compared to symptoms during the PNE test. Patients who had changed to continuous stimulation due to a suboptimal effect during follow-up reported more frequent episodes of urgency with incontinence (p = 0.034), minor soiling (p = 0.045) and days wearing pads (p = 0.027) compared with symptoms during the PNE test.

Conclusions

Cyclic stimulation seems effective for most patients treated with SNS for faecal incontinence.     

Sacral nerve stimulation for faecal incontinence secondary to congenital imperforate anus

After treatment in infancy, patients with imperforate anus can develop bowel dysfunction in adult life. Low anorectal malformations are often associated with congenital deformity of the sacrum and coccyx (sacrococcygeal agenesis). Sacral nerve stimulation (SNS) is an effective treatment for incontinent patients with an accompanying acquired sphincter defect. We report two patients treated by SNS for faecal incontinence secondary to congenital imperforate anus. Two adults presented with faecal incontinence. Both had a congenital imperforate anus. The first, a female 36 years old, suffered from lifelong incontinence. She had daily passive soiling, a sensation of incomplete emptying and urgency (less than 5 min). The second, a male 35 years old, had had incontinence since adulthood. He had urgency (2 min) and daily soiling. Both had undergone coloanal pull-through procedures in infancy. Anal manometry showed a low resting pressure in both patients (30 and 33 cm H₂O) and a reduced peak squeeze pressure increment (15 and 40 cm H₂O). Endoanal ultrasonography demonstrated a complete ring of muscle around the neo-anus in both patients. The patients underwent peripheral nerve evaluation (PNE). Both had partial sacral agenesis, which made this technically difficult. After 3 weeks of PNE, the female patient showed no improvement, but the male patient had no further episodes of incontinence and urgency improved from 2 to 15 min. Accordingly, he underwent implantation of a permanent pulse generator. SNS may be effective for some incontinent patients with imperforate anus even in the presence of partial sacral agenesis. The clinician should be aware of any associated sacral agenesis and the technical difficulty this may cause. Alternative methods of neuromodulation, such as pudendal nerve stimulation, could be considered in such cases.     

Sacral nerve stimulation in the treatment of severe faecal incontinence: long-term clinical,manometric and quality of life results

Background

Faecal incontinence (FI) is a complex and multifactorial health problem. Treatment has to be individualised, analysing the aetiology and gravity in every case. Sacral nerve stimulation (SNS) has been shown to effectively improve treatment of FI.

Methods

Fifty patients with severe FI treated with SNS between March 2002 and December 2010 were analysed. Preoperative assessment included physical examination, anorectal manometry and anal endosonography. Anal continence was evaluated using the Wexner continence grading system. Quality of life was evaluated using the Fecal Incontinence Quality of life Scale (FIQLS). Follow-up appointments were scheduled at 1, 6 and 12 months and annually thereafter. Wexner score, FIQLS and the ability to defer defecation were assessed at each visit.

Results

Fifty patients underwent a permanent implant. The overall mean follow-up period was 55.52 ± 31.84 months. After 6 months, SNS significantly improved FI and positively impacted quality of life, as evidence by significant improvements in all 4 scales of the FIQLS. Anorectal manometry showed a trend towards an increase in maximum resting pressure and maximum pressure. After the first assessment at 6 months, Wexner score and FIQLS remained stable. Ability to defer defecation was also maintained. During follow-up, 3 patients (6 %) experienced implant site pain and episodes of extremity pain and paresthesias that were refractory to medical management and required device explantation. The implant site infection rate was 2 %.

Conclusions

Analysis of our long-term results confirms the safety and effectiveness of SNS in the management of patients with FI.     

Sacral nerve stimulation versus percutaneous posterior tibial nerve stimulation in the treatment of severe fecal incontinence in men

Background

Sacral nerve stimulation and percutaneous posterior tibial nerve stimulation have been described previously as effective treatments for fecal incontinence. Nevertheless, there does not exist any study that compares the efficiency of both. The aim of this study was to compare the use of SNS and PPTNS in males with FI.

Methods

We conducted a prospective cohort study on men with FI treated with SNS or PTNS in the Coloproctology Unit of the University General Hospital of Elche and Reina Sofia of Murcia between January 2010 and December 2011. Preoperative assessment included physical examination, anorectal manometry, and anal endosonography. Anal continence was evaluated using the Wexner continence grading system. Quality of life was evaluated using the Fecal Incontinence Quality of life Scale.

Results

Nineteen patients were included (ten patients SNS and nine PPTNS). SNS improved FI in nine of the ten patients. The mean Wexner score decreased significantly from a median of 14 (12–16) (preoperative) to 4 (1–8) (6-month revision) (p = 0.007). PTNS improved FI in seven of the nine patients. The mean Wexner score decreased significantly from a median of 12 (11–19) (preoperative) to 5 (4–7) (6-month revision) (p = 0.018). Both treatments produced symptomatic improvement without statistical differences between them.

Conclusions

Our study was nonrandomized with a relatively small number of patients. PPTNS had similar efficiency to the SNS in our men population. However, more studies are necessary to exclude selection bias and analyze long-term results.

     

Sacral nerve stimulation (SNS), posterior tibial nerve stimulation (PTNS) or acupuncture for the treatment for fecal incontinence: a clinical commentary

Sacral nerve stimulation (SNS) has become an established therapy worldwide for the treatment for fecal incontinence. A large number of papers have been published over the years, and SNS is generally considered very effective with improved continence and quality of life for most patients. However, the results are mostly expressed in the semi-quantitative terms, that is, patients’ diaries translated into score points. The clinical value of SNS is questionable, especially as the patient groups are usually small and/or etiologically heterogenic and the follow-up period mostly short. The Health Technology Assessment organization in the west region of Sweden has recently evaluated the SNS with regard to evidence, efficacy and risks. Economic and ethical aspects raise serious questions on this expensive and not entirely risk-free treatment in routine medical care. Similar criticism has also been raised by other reviewers proposing a more thorough scientific assessment with well-designed randomized trials and comparison with other similar methods of treatment.     

Transcutaneous electrical nerve stimulation in osteoarthrosis: a therapeutic alternative?

Thirty patients with chronic pain due to osteoarthrosis (OA) of the knee were enrolled in a randomised double-blind cross-over trial of self-administered transcutaneous electrical nerve stimulation (TENS) and placebo TENS. Medication was standardised to paracetamol tablets only. As measured on visual analogue scales for pain relief 46% of patients responded to active therapy and 43% to placebo. The length of pain relief during active therapy was significantly longer than that during placebo. At the end of the trial more patients wanted to continue using active TENS in preference to placebo or their original medication. Although most of the parameters observed favoured active TENS, it was not possible to establish its clear superiority over placebo, because the response rate to placebo TENS was high and sustained for at least 3 weeks. This trial suggests that a longer study is required to establish the role of TENS as a therapeutic agent in the treatment of the pain of chronic arthritis.