Does magnetic stimulation of sacral nerve roots cause contraction or suppression of the bladder?

AIMS: The aim of this study was to resolve the paradox as to whether magnetic stimulation of sacral nerve roots results in contraction or suppression of the bladder, in both normal individuals and patients with spinal cord injury (SCI). MATERIALS AND METHODS: Seven males with complete SCI and neurogenic detrusor overactivity (NDO) and five normal males were investigated. Bladder capacity and maximum cystometric capacity were determined, respectively, in these groups. Magnetic stimulation was applied to sacral nerve roots using a multi-pulse magnetic stimulator and coil. Stimulation was applied at half capacity, near-full capacity, and during NDO or voiding (in normal individuals). Single and intermittent bursts of stimulation were applied. RESULTS: Neither single nor intermittent bursts of magnetic stimulation of the sacral nerve roots resulted in significant bladder pressure rises. Occasionally, following cessation of the magnetic stimulation bladder contractions were seen in patients with NDO. These contractions had an unpredictable and variable latency. As previously reported, magnetic stimulation suppressed NDO in patients with SCI, and suppressed voiding in normal individuals. CONCLUSIONS: Bladder contractions are occasionally observed in patients with NDO following withdrawal of stimulation. This phenomenon hypothetically arises as a result of removal of the bladder suppression provided by magnetic stimulation, rather than direct motor pathway stimulation (as has been reported by others). The ability of sacral magnetic stimulation to suppress detrusor contractions is reaffirmed.     

Peripheral neuromodulation via posterior tibial nerve stimulation - a potential treatment for faecal incontinence?

INTRODUCTION

Faecal incontinence is a prevalent and important condition, with a range of treatment options.Neuromodulation via sacral nerve stimulators is efficacious, but expensive and associated with complications due to device implantation. Peripheral neuromodulation via posterior tibial nerve stimulation (PTNS) has been assessed in urinary incontinence, but there is minimal evidence for its use in faecal incontinence and no literature from the UK. This retrospective review aimed to assess the efficacy of PTNS in faecal incontinence.

PATIENTS AND METHODS

Thirteen consecutive female patients with faecal incontinence of various causes (9 idiopathic, 3 obstetric, 1 surgery) underwent PTNS at a UK hospital. All were investigated with colonic imaging, anorectal physiology and endo-anal ultrasound. Prior treatments included physiotherapy (13), sphincteroplasty (3) biofeedback (3) and PTQ implants (1). PTNS was performed for 30 min, weekly for 12 weeks.

RESULTS

Median monthly episodes of incontinence of wind, liquid and solid reduced from 6, 10 and 18 respectively to 0 with 12 weeks'' treatment (P < 0.05). Significant improvements in quality of life indices were also seen. At 1-month follow up, a sustained reduction in incontinence of wind was seen (0 episodes), with non-significant reductions of liquid and solid stool.

CONCLUSIONS

PTNS is a potentially efficacious, technically simple and minimally invasive alternative treatment modality for faecal incontinence. These early results are encouraging, but we await medium- and long-term follow-up, and a larger randomised trial comparing PTNS with alternative treatments and placebo.     

Can we predict the response in the treatment of epilepsy with vagus nerve stimulation?

Despite the introduction of new antiepileptic drugs and advances in the surgical treatment of epilepsy, an important group of patients still remains uncontrolled by any of these methods. The relatively recent introduction of vagus nerve stimulation is yet another possible treatment for refractory epilepsy. This safe, simple, and adjustable technique reduces the number of seizures and multiple publications support its increasing efficacy and effectiveness, with few adverse effects. The goal of our study is to determine the efficacy of this procedure and the factors predicting a response, particularly in the presence of a temporal lobe discharge on the video electroencephalogram (video-EEG) and magnetic resonance imaging (MRI) lesions. We undertook a retrospective study of all the patients with refractory epilepsy who underwent implantation of a vagus nerve stimulator between 2003 and 2009, and with a minimum follow-up of 6 months. The statistical analysis was done with SPSS for Windows. The stimulator was implanted in 40 patients, of whom 38 had a minimum follow-up of 6 months. In one patient, the device had to be removed due to infection, so the series comprised 37 patients. These were divided into different groups, according to the epidemiologic, clinical, radiologic, and electroencephalographic data. In addition, an analysis of the response was performed. The efficacy of the procedure was established according to the reduction in the mean seizure frequency. The baseline value of these seizures was 80.97?±?143.59, falling to 37?±?82.51 at the last revision. The response rate (reduction in seizures ≥50 %) at 6 months was 51.4 %, with 62.2 % of the patients showing this reduction at the last evaluation. Significant differences in the response were seen for the variables: baseline frequency of seizures, temporal lobe discharge on VideoEEG and MRI lesions. The mean time to response was 10 months in patients with lower rate of seizures versus 25 months of those with the higher rate (p?=?0.024), and the response at 6 months was higher (p?=?0.05). Patients with temporal lobe discharge alone or in combination with discharges over other regions had a mean time to response of 11 months versus 26 months in those without temporal discharge (p?=?0.037). In the analysis of the MRI, we had seen that at the last revision, 82.4 % of the patients with lesion had achieved response versus 45 % without lesion (p?=?0.02). Vagus nerve stimulation reduces the frequency of seizures. A temporal lobe discharge on the video-EEG is an indicator of an early response and the presence of an MRI lesion indicates a late response. Patients with fewer rates of seizures have a better prognosis.     

Percutaneous tibial nerve stimulation can improve symptoms and quality of life in selected patients with faecal incontinence – A single-centre 5-year clinical experience

IntroductionFaecal incontinence is a debilitating condition that affects a significant proportion of the population. Conservative management remains the mainstay of treatment but surgical intervention such as neuromodulation can be indicated in cases refractory to medical therapy.AimThe aim of this study was to review the outcomes of patients who underwent percutaneous tibial nerve stimulation (PTNS) for faecal incontinence and urgency in a single institution over five years.ResultsEighty-one patients completed the 12-week trial of PTNS with a success rate of 80% (n = 64/81). Rates of faecal incontinence and urgency were reduced from 13 episodes per fortnight to 3 and from 10 to 3 respectively. Over a median follow up of 2 years (range 0–5 years) reduction in rates of faecal urgency and incontinence were maintained. Quality of life parameters were measured using a variety of established questionnaires. Improvements were observed in the majority of parameters that were maintained throughout the follow up period.ConclusionPercutaneous tibial nerve stimulation is one of the forms of neuromodulation available for the treatment of faecal incontinence and urgency in patients who failed conservative management. This study has shown that in carefully selected, motivated patients, the use of PTNS in conjunction with regular counseling from a specialist practitioner in pelvic floor disorders can improve both the symptoms and quality of life of patients with faecal urgency and mild faecal incontinence with improvements in symptomology maintained for up to 5 years.     

The use of Permacol? injections for the treatment of faecal incontinence

The aim of this study is to assess the safety and efficacy of Permacol^? implant for the treatment of idiopathic faecal incontinence using a novel injection technique. Patients with idiopathic passive faecal incontinence were selected for trans-submucosal injection of Permacol^? after assessment by anorectal physiology and endoanal ultrasonography. Clinical assessment and St. Mark??s Incontinence Score were used to evaluate efficacy before and at two time points (1 and 2?years) after treatment. Rockwood Score were also used to determine quality of life before and after treatment. The Friedman and Chi-square tests were used to compare continuous and categorical data, respectively. A p value of <0.05 was deemed significant. Thirty-eight patients (24 female), median age 66?years, were recruited. At maximum clinical follow-up (median of 9?months), response to Permacol^? injections was categorised as excellent, good, fair and poor in 12, 5, 4 and 17 patients, respectively. St. Mark??s Score improved in 72 and 63?% of patients at 1 and 2?years, respectively. However, a smaller proportion of patients (39 and 27?%, respectively) achieved a 50?%, or more, improvement in Mark??s Score. All four domains of Rockwood Quality of Life Score improved on first and second year follow-up, however, only two domains, coping and embarrassment, were statistically significant. Permacol^? injection improved symptoms by >50?% in 39 and 27?% of patients on short and medium-term follow-ups, respectively. The trans-submucosal technique for injection of Permacol^? in this study was safe with no significant adverse outcomes.     

Does concomitant stress incontinence alter the efficacy of tolterodine in patients with overactive bladder?

PURPOSE: Muscarinic antagonists such as tolterodine are the treatment of choice for overactive bladder (OAB). We determined the impact of concomitant stress incontinence (SI) on the therapeutic effects of tolterodine in patients with OAB with and without concomitant SI. MATERIALS AND METHODS: Data from an open label, observational study involving 2,250 patients with OAB symptoms were analyzed for baseline frequency, urgency and incontinence, and alterations in these symptoms while on 12-week treatment with 2 mg tolterodine twice daily. Data are shown as the mean +/- SD. The statistical significance of differences in treatment effects was determined by multiple regression analysis, adjusting for gender, age and baseline symptom intensity. RESULTS: Concomitant I to III degree SI according to the Stamey grading was present in 31%, 15% and 2% of patients, respectively, and it was associated with increasing basal incontinence, although only III degree SI was associated with greater baseline frequency or urgency. In the overall group tolterodine decreased frequency, urgency and urge incontinence from 12.4 +/- 4.3 to 7.7 +/- 2.7, 8.4 +/- 5.1 to 2.0 +/- 3.0 and 3.4 +/- 4.2 to 0.8 +/- 2.0 episodes daily, respectively. On multiple linear regression analysis I and II degree SI had a minor, if any, effect on this improvement, while III degree SI was statistically associated with a smaller decrease in frequency (by 1.4 +/- 0.4 micturitions daily, p = 0.0002) and incontinence (by 2.1 +/- 0.3 episodes daily, p < 0.0001) but with similar alterations in the number of urge episodes. CONCLUSIONS: Concomitant I or II degree SI has little effect on the efficacy of tolterodine in OAB cases. Only patients with concomitant III degree SI have significantly less improvement.     

Treatment of urinary incontinence in men with electrical stimulation: Is practice evidence-based?

Electrical stimulation is frequently recommended for the treatment of urinary incontinence in men. However, few randomized, controlled trials allow practitioners to evaluate the evidence base for this practice. The purpose of this article is to determine, based on a review of the literature, whether adequate evidence exists to support the use of electrical stimulation as a treatment of male urinary incontinence. Urge, stress, and overflow incontinence are evaluated separately. This review led to 3 conclusions: (1) theoretical and urodynamic evidence exists to support the use of electrical stimulation for urge incontinence, (2) conflicting evidence exists in the use of electrical stimulation for stress urinary incontinence, and (3) treatment of overflow incontinence in men has not been evaluated in a systematic way. For both stress urinary or overflow incontinence, practitioners should consider the existing research before recommending electrical stimulation as a first line of treatment. For urge incontinence, electrical stimulation may be an effective first-line treatment strategy.     

Low muscle volume of the anal sphincter complex: A novel prognostic factor in children with anorectal malformations?

Background/PurposeThe anal sphincter complex (ASC) plays a key role in continence and is often dysfunctional in infants born with anorectal malformations (ARM). The ASC is well depicted by magnetic resonance (MR) imaging but volumetric reference data are lacking in infants. Thus, we tested the feasibility of MR based ASC volumetry, collected reference data, and compared them with cases of favorableprognosis and unfavorable prognosis (as defined by the type of ARM).MethodsWe determined ASC volume on T2 weighted MR images of seventy six infants (ARM n = 33; controls n = 43) by manual segmentation. Inter operator agreement was assessed by intraclass correlation coefficient. Linear regression was used to establish weight dependent reference data. Observed to expected ASC volumes of patients with unfavorable and favorable prognosis were compared (unpaired t test).ResultsASC volumetry was feasible in all cases. Patients with ARM had low ‘observed to expected’ ASC volume ( 18.1%; p = 0.006). ‘Observed to expected’ ASC volume differed significantly between patients with favorableand unfavorable prognosis (p < 0.001).ConclusionWe confirmed the feasibility of MRI based ASC volumetry and provided initial reference data for infants. Although ASC volumes were lowest in infants with ARM of unfavorable prognosis for fecal continence, the value of ASC volume as prognostic parameter remains to be determined.