The efficacy of posterior tibial nerve stimulation for the treatment of overactive bladder in women: a systematic review

Introduction and hypothesis

Posterior tibial nerve stimulation (PTNS) is a percutaneous method of peripheral, sacral neuromodulation. Its current use is limited; however, published data suggest PTNS may be an effective treatment for overactive bladder (OAB).

Methods

We systematically reviewed the literature on PTNS for treatment of idiopathic OAB in women from January 2000 to August 2010 published in English in MEDLINE/PubMed, Embase, and Cochrane databases. We included randomized controlled trials or observational studies reporting objective outcome measures with the use of either the Urgent PC or Stoller Afferent Nerve Stimulator (SANS) for PTNS. Studies were considered “good quality” if results from objective measures were provided for ≥20 women, results distinguished between type of OAB symptom, and data were reported separately for female subjects.

Results

Of the 136 identified articles, 17 met inclusion criteria for data abstraction; 4 of the 17 studies met our criteria for good quality and reported success rates of 54–93?%. Recurrent limitations in the literature were pooling of results for male and female subjects and lack of differentiation in the data on specific symptoms of OAB treated. Short-term follow-up and infrequent use of a control arm were also noted shortcomings of reviewed studies.

Conclusions

Limited high quality data exist on PTNS for OAB in women. Although initial studies have demonstrated promise, more comprehensive evaluation of PTNS is needed to support its universal use for the treatment of OAB in women.     

Home-based transcutaneous tibial nerve stimulation for overactive bladder syndrome: a randomized,controlled study

International Urology and Nephrology - Transcutaneous posterior tibial nerve stimulation (TPTNS) for the treatment of overactive bladder syndrome (OAB), with or without urge urinary incontinence...     

Urodynamic effect of acute transcutaneous posterior tibial nerve stimulation in overactive bladder

PURPOSE: Of the various treatments proposed for urge incontinence, frequency and urgency electrostimulation has been widely tested. Different techniques have been used with the necessity of surgical implantation (S3 neuromodulation or sacral root stimulation) or without requiring surgery (perineal transcutaneous electrostimulation). Recently peripheral electrical stimulation of the posterior tibial nerve was proposed for irritative symptoms in first intention or for intractable incontinence. Clinical studies have demonstrated good results and urodynamic parameters were improved after chronic treatment. However, to our knowledge no data concerning acute stimulation and immediate cystometry modifications have been reported. We verified urodynamic changes during acute posterior tibial nerve stimulation. MATERIALS AND METHODS: A total of 44 consecutive patients with urge incontinence, frequency and urgency secondary to overactive bladder were studied. There were 29 women and 15 men with a mean age +/-SD of 53.3 +/- 18.2 years. Of the patients 37 had detrusor hyperreflexia due to multiple sclerosis (13), spinal cord injury (15) or Parkinson's disease (9), and 7 had idiopathic detrusor instability. Routine cystometry at 50 ml. per minute was done to select the patients with involuntary detrusor contractions appearing before 400 ml. maximum filling volume. Repeat cystometry was performed immediately after the first study during left posterior tibial nerve stimulation using a surface self-adhesive electrode on the ankle skin behind the internal malleolus with shocks in continuous mode at 10 Hz. frequency and 200 milliseconds wide. Volume comparison was done at the first involuntary detrusor contraction and at maximum cystometric capacity. The test was considered positive if volume at the first involuntary detrusor contraction and/or at maximum cystometric capacity increased 100 ml. or 50% during stimulation in compared with standard cystometry volumes. RESULTS: Mean first involuntary detrusor contraction volume on standard cystometry was 162.9 +/- 96.4 ml. and it was 232.1 +/- 115.3 ml. during posterior tibial nerve stimulation. Mean maximum cystometric capacity on standard cystometry was 221 +/- 129.5 ml. and it was 277.4 +/- 117.9 ml. during stimulation. Posterior tibial nerve stimulation was associated with significant improvement in first involuntary detrusor contraction volume (p <0.0001) and significant improvement in maximum cystometric capacity (p <0.0001). The test was considered positive in 22 of the 44 patients. CONCLUSIONS: These results suggest an objective acute effect of posterior tibial nerve stimulation on urodynamic parameters. Improved bladder overactivity is an encouraging argument to propose posterior tibial nerve stimulation as a noninvasive treatment modality in clinical practice.     

A comparison of extended-release oxybutynin and tolterodine for treatment of overactive bladder in women

Women with urge or mixed incontinence were randomized to a daily dose of 10 mg extended-release oxybutynin chloride (qd) or tolterodine tartrate 4 mg (2 mg bid) for 12 weeks. Subjects completed 7-day voiding diaries at baseline and at 12 weeks. A total of 315 women were treated. At the end of the study, extended-release oxybutynin chloride was more effective than twice-daily tolterodine tartrate as measured by urge and total incontinence episodes (p=0.038, p=0.030, respectively). Overall, the reduction in micturition frequency between groups was not significantly different. In women aged 64 years and younger (comprising 63% of the population) extended-release oxybutynin was more effective than tolterodine for urge (p=0.005) and total incontinence (p=0.005), and for micturition frequency (0.024). Adverse events were infrequent, mostly mild, and similar between treatment groups. We concluded that daily extended-release oxybutynin chloride (10 mg) was more effective than tolterodine tartrate (2 mg bid) in treating urge and total incontinence. The incidences of dry mouth, CNS events, and other adverse events were similar for both drugs.     

Percutaneous tibial nerve stimulation in the treatment of overactive bladder: urodynamic data.

AIM: The aim of this study was to evaluate urodynamic changes after percutaneous tibial nerve stimulation (PTNS) for the treatment of complaints related to overactive bladder syndrome and to search for urodynamic-based predictive factors. METHODS: Ninety consecutive patients with symptoms related to overactive bladder syndrome were enrolled in this study. Patients underwent 12 PTNS sessions. For evaluating objective success, the primary outcome measure was a reduction in number of urinary leakage episodes of 50% or more per 24 hours. Patients' request for continuation of therapy was considered subjective success. This study focussed on urodynamic features at baseline and on changes found after 12 PTNS treatments. RESULTS: The objective success rate was 56% (leakages/24 hours). Subjective success rate was 64%. Frequency/volume chart data and quality of life scores improved significantly (P < 0.01). Pre- and posturodynamic data were available from 46 participants. Detrusor instabilities (DI) could be abolished in a few cases only. Increments in cystometric bladder capacity and in volume at DI were significant (P = 0.043 and 0.012, respectively). Subjects without detrusor instabilities at baseline were 1.7 times more prone to respond to PTNS (odds ratio, 1.75; 95% confidence interval [CI], 0.67-4.6). The more the bladder overactivity was pronounced, the less these patients were found to respond to PTNS, the area under the receiver operating curve was 0.644 (95% CI, 0.48-0.804). CONCLUSION: PTNS could not abolish DI. PTNS increased cystometric capacity and delayed the onset of DI. Cystometry seemed useful to select good candidates: patients without DI or with late DI onset proved to be the best candidates for PTNS.     

Sacral nerve stimulation for the overactive bladder

Pharmacotherapy is the first-line treatment for overactive bladder, but many patients discontinue drug therapy because of intolerable side effects, expense, or lack of longterm adherence. Alternative treatments are needed for patients who are unable to tolerate pharmacotherapy or who do not derive the desired benefits. Sacral nerve stimulation therapy has evolved into one of the most widely accepted treatment modalities in the arena of neurourology. Sacral nerve stimulation activates or "resets" the somatic afferent inputs that play a pivotal role in the modulation of sensory processing for micturition reflex pathways in the spinal cord. This minimally invasive technology offers a safe, reliable, and durable treatment for lower urinary tract dysfunction.     

First Scandinavian experience of electrical sacral nerve stimulation in the treatment of the overactive bladder

OBJECTIVE: This study aimed to evaluate the efficacy of electrical sacral nerve stimulation (SNS) in the treatment of urinary incontinence and urinary retention refractory to conservative treatment, and to assess the impact of urodynamic abnormalities and electrode position. MATERIAL AND METHODS: Thirty patients (10 men, 20 women) with a mean age of 59 years (range 21-79 years), all of whom had longstanding symptoms ranging from 2 to 46 years (mean 12.4 years), were subjected to a percutaneous test stimulation. Ten patients responded well, resulting in a permanent implant in nine patients. Electrode positions were determined by plain X-ray and computed tomography. RESULTS: Radiologically, a variety of positions of the temporary electrodes was seen. In the implanted patients, long-term symptom reduction varied over time, ranging from total relief to partial or total recurrence of symptoms. CONCLUSIONS: SNS is a new promising option for the treatment of urge incontinence. Refined instruments for proper patient selection and the optimal way to position the electrode remain to be developed.     

Urinary nerve growth factor in women with overactive bladder syndrome

Study Type – Aetiology (case series) Level of Evidence 4 What’s known on the subject? and What does the study add? Urinary nerve growth factor levels were higher in women with OAB‐dry and OAB‐wet compared to the controls. The link between female OAB and risk factors such as obesity and menopause has not been determined yet. This study found ageing, menopause, or higher BMI did not influence the urinary NGF levels in OAB women. Higher urinary NGF levels in OAB women could be an inflammatory disorder unrelated to ageing or obesity.

OBJECTIVE

? To measure urinary nerve growth factor (NGF) in women with overactive bladder (OAB)‐dry and OAB‐wet and investigate the association of urinary NGF expression with these factors.

PATIENTS AND METHODS

? Differentiation between OAB‐wet and OAB‐dry was based on symptoms and a 3‐day voiding diary. ? Urinary NGF levels were measured by enzyme‐linked immunosorbent assay (ELISA). ? The urinary NGF levels were compared among controls, OAB‐dry and OAB‐wet subgroups, and also between OAB patients ≥55 years and <55 years, as well as between patients with a body mass index (BMI, kg/m²) <20, 20–30 and >30.

RESULTS

? A total of 113 women with OAB‐dry, 106 with OAB‐wet and 84 controls were enrolled. The urinary NGF/creatinine (Cr) levels were significantly highest in OAB‐wet (2.13 ± 3.87) and second highest in OAB‐dry (0.265 ± 0.59) compared to controls (0.07 ± 0.21). ? Analysis of urinary NGF or NGF/Cr levels among controls, OAB‐dry and OAB‐wet groups by age and BMI showed no significant differences, except for the OAB‐dry group. ? Urinary NGF/Cr was not significantly correlated with age (P= 0.088) or BMI (P= 0.886) in women with OAB‐dry and OAB‐wet.

CONCLUSIONS

? Urinary NGF levels were significantly higher in women with OAB‐dry and even higher in women with OAB‐wet. ? The urinary NGF level was not associated with ageing, menopause or higher BMI either in controls or OAB patients.     

Transcutaneous posterior tibial nerve stimulation: evaluation of a therapeutic option in the management of anticholinergic refractory overactive bladder

Introduction and hypothesis

This study evaluated the efficacy and tolerability of transcutaneous posterior tibial nerve stimulation (TPTNS) in the treatment of overactive bladder (OAB) after failure of a first-line anticholinergic treatment.

Materials and methods

We performed a prospective observational study and included all patients treated in a single center for OAB persisting after first-line anticholinergic treatment from November 2010 to May 2013. The protocol consisted of daily stimulation at home. The efficacy end point was defined as improvement on the Urinary Symptom Profile (USP) and the French-validated urinary symptom score Mesure du Handicap Urinaire (MHU).

Results

We assessed 43 consecutive patients. TPTNS was successful following 1 month of treatment in 23 (53 %) patients. Bladder capacity was the only predictive factor for treatment success (p?=?0.044). For patients who showed improved symptoms (n?=?23; 53 %), mean MHU and USP decreased significantly, from 11.8 ± 2.8 to 5.6 ± 3 (p?<?0.001) and from 14 ± 3.3 to 6.9 ± 3.2 (p?<?0.001), respectively. After a mean follow-up of 10.8 ± 1.6 months, 21 (49 %) patients continued the TPTNS. Mean MHU and USP scores were 4.4 ± 2.8 and 5.4 ± 3.5, respectively, and stayed lower than baseline (p?<?0.001). Patients reported no adverse events.

Conclusion

TPTNS is well tolerated and is effective in one half of the patients studied after they failed anticholinergic treatment. TPTNS could become a second therapeutic option before surgical treatment in the management strategy of OAB.     

Sustained effectiveness of percutaneous tibial nerve stimulation for overactive bladder syndrome: 2-year follow-up of positive responders

Introduction and hypothesis

The aim of the study was to describe effectiveness and safety of percutaneous tibial nerve stimulation (PTNS) at 2 years in women with overactive bladder (OAB) syndrome unresponsive to pharmacotherapy.

Methods

Of 30 women who had initial positive response to PTNS, 23 continued to receive maintenance treatment and were reassessed at 2 years using bladder symptom diaries and the Incontinence Impact Questionnaire (IIQ-7). They were also questioned on acceptability and any adverse effects of long-term peripheral neuromodulative treatment.

Results

Data from 23 women were available and 7 had been lost to follow-up. With maintenance treatment, the median nocturnal frequency at 2 years had decreased by 57 % (3.5 to 1.5 times/night), while the median IIQ-7 had reduced from 30.4 to 21.5 (both p?<?0.01) compared to pre-treatment baseline. Median nocturnal frequency and IIQ-7 scores at 2 years were comparable to those documented after initial response to treatment at 6 weeks, suggesting that maintenance therapy continued to suppress OAB symptoms. Daytime frequency and daily urgency incontinence episodes at 2 years were statistically similar to those documented at 6 weeks and remained lower than pre-treatment baseline (6.5 vs 11.8 and 2.0 vs 3.5, respectively, p?<?0.05). The women received a median of 8.42 treatments per year and the median length between treatments was 64.3 days. Apart from hypaesthesia in the toe of one responder lasting for 4 months, there were no reported side effects.

Conclusions

Women receiving PTNS for intractable OAB syndrome reported significant symptom relief at 2 years. This remains a safe mode of second-line treatment with excellent durability.