Percutaneous Tibial Nerve Stimulation for Refractory Lower Urinary Tract Symptoms in Patients with Neurogenic Bladder Conditions TREATMENT options for refractory lower urinary tract symptoms (LUTS) in patients with a variety of neurological disorders remain limited. Much of the failure in our ability to ameliorate these symptoms is due to the profound impact of many of these conditions directly on bladder function. Other challenges, such as functional limitations limiting adequate access to toileting facilities, also present a vexing problem for many patients. The development of beta-agonists and the approval of onabotulinumtoxin A for the treatment of urgency incontinence in the setting of neurogenic detrusor overactivity (DO) has greatly improved our ability to offer viable alternatives to patients with overactive bladder (OAB) and urgency incontinence. Nevertheless, treatment of patients with neurogenic bladder (NGB) conditions resulting in voiding dysfunction/ impaired voiding remains quite challenging. Hope is certainly provided by the results of Zecca et al in this issue of The Journal (page 697).1 In patients with multiple sclerosis (MS) and refractory mixed symptoms (storage and emptying) treated with percutaneous tibial nerve stimulation (PTNS), sustained treatment benefit (2 years) was noted in the majority of patients with a typical maintenance treatment interval of 3 weeks. Perhaps the most encouraging aspect of this finding is the benefit not only in OAB symptoms, but clear improvement in voiding and voiding efficiency. For obvious reasons, the ability of a minimally invasive approach using a nonimplantable technique to provide benefit to patients who frequently have multiple medical problems and may require repeat magnetic resonance imaging is a welcome tool in our armamentarium. Indeed during the last several years data have been accumulating that LUTS and physiological indices of bladder function can be directly impacted by a variety of forms of neuromodulation. Pudendal nerve stimulation, perianal stimulation and sacral neuromodulation have all been shown to directly affect overactive bladder contractions. Peripheral
0022-5347/14/1913-0582/0 THE JOURNAL OF UROLOGY® © 2014 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION
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(tibial) afferent nerve stimulation, which was first attempted for urological use in the 1980s by McGuire et al,2 and then further investigated/ modified by Stoller,3 has shown durable, reliable efficacy in the treatment of overactive bladder conditions4 and, to a lesser extent, voiding dysfunction5 in nonneurogenic populations. The use of neuromodulation techniques, and in particular PTNS, in patients with NGB conditions has only more recently been assessed. Urodynamic studies have demonstrated acute and subacute improvements in several parameters after stimulation.6,7 During PTNS treatment in patients with Parkinson disease, significant increases in mean cystometric capacity and threshold volume for first DO have been noted. Similarly after a typical 12-week treatment paradigm in patients with MS, cystometric capacity and threshold volume for DO were significantly increased while residual volume, maximum detrusor pressure and voiding pressure were all decreased. Nevertheless, acute elimination of neurogenic DO in patients with MS appears to be unlikely during PTNS.8 Symptom improvement has also been noted particularly in patients with MS. The OAB symptom score was improved by more than 50% in a group of patients with MS treated for 12 weeks, while improvements in urgency episodes, incontinence episodes, nocturia, and pad use have all been reported during a similar time frame.7 The first multi-institutional study on the use of PTNS in patients with MS refractory to treatment with at least 2 anticholinergics was reported in 2011.9 Significant improvements in LUTS were noted in 89% of participants and most domains of the King’s Health Questionnaire showed substantial improvements. Nocturia, often a troubling problem for this group of patients due to mobility concerns, improved from an average of 3 episodes per night to once nightly, while daytime frequency decreased from 9 to 6 episodes. Age, disease duration, subtype and gender did not correlate with success.
http://dx.doi.org/10.1016/j.juro.2013.12.024 Vol. 191, 582-583, March 2014 Printed in U.S.A.
PERCUTANEOUS TIBIAL NERVE STIMULATION FOR LOWER URINARY TRACT SYMPTOMS
New forms of peripheral transcutaneous neuromodulation are in development. Indeed, one transcutaneous form of posterior tibial nerve stimulation has been used in patients with MS.10 After learning how to apply the electrode in the office, patients did so at home and used electrical stimulation daily for 20 minutes during a 3-month period. Promising data were reported with improvements in urgency, frequency and bother. Complete continence was achieved in 45% of patients. A natural evolution of neuromodulation techniques has occurred during the last 2 decades. Less invasive approaches that can potentially be applied at home or applied in an office setting and maintained at home are inevitable and welcome. In
583
addition, the extension of the use of these techniques to a wider range of patients with troublesome LUTS, such as those with NGB conditions, is to be expected. These advances will shape our approach to the treatment of LUTS in a group of patients with NGB who are often the most seriously affected by OAB conditions.11 Gary E. Lemack* Department of Urology UT Southwestern Medical Center Dallas, Texas *Financial interest and/or other relationship with Afferent Pharmaceuticals, Ferring, Merck, Pfizer, Astellas and Allergan.
REFERENCES 1. Zecca C, Digesu GA, Robshaw P et al: Maintenance percutaneous posterior nerve stimulation for refractory lower urinary tract symptoms in patients with multiple sclerosis: an open label, multicenter, prospective study. J Urol 2014; 191: 697. 2. McGuire EJ, Zhang SC, Horwinski ER et al: Treatment of motor and sensory detrusor instability by electrical stimulation. J Urol 1983; 129: 78. 3. Stoller ML: Afferent nerve stimulation for pelvic floor dysfunction. Eur Urol 1999; 35: 16. 4. MacDiarmid SA, Peters KM, Shobeiri SA et al: Long-term durability of percutaneous tibial nerve stimulation for the treatment of overactive bladder. J Urol 2010; 183: 234. 5. Vandoninck V, van Balken MR, Finazzi Agro E et al: Posterior tibial nerve stimulation in the
treatment of voiding dysfunction: urodynamic data. Neurourol Urodyn 2004; 23: 246. 6. Kabay SC, Kabay S, Yucel M et al: Acute urodynamic effects of percutaneous posterior tibial nerve stimulation on neurogenic detrusor overactivity in patients with Parkinson’s disease. Neurourol Urodyn 2009; 28: 62. 7. Kabay S, Kabay SC, Yucel M et al: The clinical and urodynamic results of a 3-month percutaneous posterior tibial nerve stimulation treatment in patients with multiple sclerosis-related neurogenic bladder dysfunction. Neurourol Urodyn 2009; 28: 964. 8. Fjorback MV, van Rey F, van der Pal F et al: Acute urodynamic effects of posterior tibial nerve stimulation on neurogenic detrusor overactivity in patients with MS. Eur Urol 2007; 51: 464.
9. Gobbi C, Digesu GA, Khullar V et al: Percutaneous posterior tibial nerve stimulation as an effective treatment of refractory lower urinary tract symptoms in patients with multiple sclerosis: preliminary data from a multicentre, prospective, open label trial. Mult Scler 2011; 17: 1514. 10. De Seze M, Raibaut P, Gallien P et al: Transcutaneous posterior tibial nerve stimulation for treatment of the overactive bladder syndrome in multiple sclerosis: results of a multicenter prospective study. Neurourol Urodyn 2011; 30: 306. 11. Hall SA, Curto TM, Onyenwenyi A et al: Characteristics of persons with overactive bladder of presumed neurologic origin: results from the Boston Area Community Health (BACH) Survey. Neurourol Urodyn 2012; 31: 1149.
0022-5347/14/1913-0582/0 THE JOURNAL OF UROLOGY® © 2014 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION
582
j
www.jurology.com
AND
RESEARCH, INC.
(tibial) afferent nerve stimulation, which was first attempted for urological use in the 1980s by McGuire et al,2 and then further investigated/ modified by Stoller,3 has shown durable, reliable efficacy in the treatment of overactive bladder conditions4 and, to a lesser extent, voiding dysfunction5 in nonneurogenic populations. The use of neuromodulation techniques, and in particular PTNS, in patients with NGB conditions has only more recently been assessed. Urodynamic studies have demonstrated acute and subacute improvements in several parameters after stimulation.6,7 During PTNS treatment in patients with Parkinson disease, significant increases in mean cystometric capacity and threshold volume for first DO have been noted. Similarly after a typical 12-week treatment paradigm in patients with MS, cystometric capacity and threshold volume for DO were significantly increased while residual volume, maximum detrusor pressure and voiding pressure were all decreased. Nevertheless, acute elimination of neurogenic DO in patients with MS appears to be unlikely during PTNS.8 Symptom improvement has also been noted particularly in patients with MS. The OAB symptom score was improved by more than 50% in a group of patients with MS treated for 12 weeks, while improvements in urgency episodes, incontinence episodes, nocturia, and pad use have all been reported during a similar time frame.7 The first multi-institutional study on the use of PTNS in patients with MS refractory to treatment with at least 2 anticholinergics was reported in 2011.9 Significant improvements in LUTS were noted in 89% of participants and most domains of the King’s Health Questionnaire showed substantial improvements. Nocturia, often a troubling problem for this group of patients due to mobility concerns, improved from an average of 3 episodes per night to once nightly, while daytime frequency decreased from 9 to 6 episodes. Age, disease duration, subtype and gender did not correlate with success.
http://dx.doi.org/10.1016/j.juro.2013.12.024 Vol. 191, 582-583, March 2014 Printed in U.S.A.
PERCUTANEOUS TIBIAL NERVE STIMULATION FOR LOWER URINARY TRACT SYMPTOMS
New forms of peripheral transcutaneous neuromodulation are in development. Indeed, one transcutaneous form of posterior tibial nerve stimulation has been used in patients with MS.10 After learning how to apply the electrode in the office, patients did so at home and used electrical stimulation daily for 20 minutes during a 3-month period. Promising data were reported with improvements in urgency, frequency and bother. Complete continence was achieved in 45% of patients. A natural evolution of neuromodulation techniques has occurred during the last 2 decades. Less invasive approaches that can potentially be applied at home or applied in an office setting and maintained at home are inevitable and welcome. In
583
addition, the extension of the use of these techniques to a wider range of patients with troublesome LUTS, such as those with NGB conditions, is to be expected. These advances will shape our approach to the treatment of LUTS in a group of patients with NGB who are often the most seriously affected by OAB conditions.11 Gary E. Lemack* Department of Urology UT Southwestern Medical Center Dallas, Texas *Financial interest and/or other relationship with Afferent Pharmaceuticals, Ferring, Merck, Pfizer, Astellas and Allergan.
REFERENCES 1. Zecca C, Digesu GA, Robshaw P et al: Maintenance percutaneous posterior nerve stimulation for refractory lower urinary tract symptoms in patients with multiple sclerosis: an open label, multicenter, prospective study. J Urol 2014; 191: 697. 2. McGuire EJ, Zhang SC, Horwinski ER et al: Treatment of motor and sensory detrusor instability by electrical stimulation. J Urol 1983; 129: 78. 3. Stoller ML: Afferent nerve stimulation for pelvic floor dysfunction. Eur Urol 1999; 35: 16. 4. MacDiarmid SA, Peters KM, Shobeiri SA et al: Long-term durability of percutaneous tibial nerve stimulation for the treatment of overactive bladder. J Urol 2010; 183: 234. 5. Vandoninck V, van Balken MR, Finazzi Agro E et al: Posterior tibial nerve stimulation in the
treatment of voiding dysfunction: urodynamic data. Neurourol Urodyn 2004; 23: 246. 6. Kabay SC, Kabay S, Yucel M et al: Acute urodynamic effects of percutaneous posterior tibial nerve stimulation on neurogenic detrusor overactivity in patients with Parkinson’s disease. Neurourol Urodyn 2009; 28: 62. 7. Kabay S, Kabay SC, Yucel M et al: The clinical and urodynamic results of a 3-month percutaneous posterior tibial nerve stimulation treatment in patients with multiple sclerosis-related neurogenic bladder dysfunction. Neurourol Urodyn 2009; 28: 964. 8. Fjorback MV, van Rey F, van der Pal F et al: Acute urodynamic effects of posterior tibial nerve stimulation on neurogenic detrusor overactivity in patients with MS. Eur Urol 2007; 51: 464.
9. Gobbi C, Digesu GA, Khullar V et al: Percutaneous posterior tibial nerve stimulation as an effective treatment of refractory lower urinary tract symptoms in patients with multiple sclerosis: preliminary data from a multicentre, prospective, open label trial. Mult Scler 2011; 17: 1514. 10. De Seze M, Raibaut P, Gallien P et al: Transcutaneous posterior tibial nerve stimulation for treatment of the overactive bladder syndrome in multiple sclerosis: results of a multicenter prospective study. Neurourol Urodyn 2011; 30: 306. 11. Hall SA, Curto TM, Onyenwenyi A et al: Characteristics of persons with overactive bladder of presumed neurologic origin: results from the Boston Area Community Health (BACH) Survey. Neurourol Urodyn 2012; 31: 1149.
