REVIEW OF THE ROLE OF PERCUTANEOUS TIBIAL NERVE STIMULATION IN THE TREATMENT OF OVER ACTIVE BLADDER
Mohammad Ibrahim Abd Eltawab;
Abstract
Overactive bladder (OAB) is a “symptom syndrome”, marked by urgency, with or without urge incontinence, usually with frequency and nocturia, if there is no proven infection or other obvious pathology. The medical, social, and economic impact of overactive bladder is astonishing. As, the numbers of affected individuals are projected to increase with time, with the greatest increase in burden anticipated in developing regions.
Excluding psychological reasons, generally, bladder over activity results either in absence of any associated other pathology affecting urinary tract according to Abrams and his colleges definition in 2002 or from abnormality either secondary to anatomical abnormalities, histological abnormal changes, neurological abnormalities or a combination as other authors believe in.
Overactivity of the detrusor muscle may be due to neurogenic, myogenic or idiopathic, and all of the previously mentioned subtypes of DO can result in urgency or urge incontinence, depending on the response of the internal urethral sphincter. Also disturbing and insulting the normal urothelial lining of the urinary bladder, unmyelinated C sensory fibers activation and suburothelial ICC-like cells play an important role in pathogenesis of OAB and DO.
In neurogenic DO, a popular classification is based on the location of the neurologic lesion. In myogenic DO, the theory postulates that unstable increase in intravesical pressure during involuntary detrusor contraction may result in periodic ischemia of bladder, resulting in damage to some intrinsic neurons in the bladder wall and secondary changes in the smooth muscle properties.
There are many conditions and diseases, which could cause LUTD such as BPE, OAB, UTI, and etc…. And they are characterized by presence of common symptoms such as frequency, urgency and other LUTS that may cause intermixing and misdiagnosis of the case. For this reason, a careful medical assessment is a prerequisite for LUTD to determine the cause and to reach a proper treatment plan.
The assessment tools for LUTD generally and OAB especially includes careful medical history, an abdominal and pelvic examination including digital rectal examination or palpation of vagina DRE/PV, also neurological examination, Frequency-volume charts and voiding diaries, and laboratoryevaluation including different type of labs. especially urinalysis. Urinary tract imaging and urethrocystoscopy are useful in certain cases either in diagnosis of the cause or in detecting any complications.
Uroflowmetry and PVR serve as noninvasive screening tests for selecting patients who should undergo more sophisticated urodynamic studies and for evaluating treatment effect during follow-up. Uroflowmetry alone is insufficient for distinguishing detrusor muscle dysfunction or urinary outlet abnormalities. If the initial evaluation indicates patients with myogenic or neurogenic caused voiding dysfunction, complete urodynamics including videourodynamics should be performed.
The therapy for OAB can be divided into the following classes of treatment: conservative management, pharmacotherapy, and surgical therapy. Usually the conservative management of OAB is not enough alone and usually pharmacotherapy is needed depending mainly on antimuscarinic medications. But, unfortunately, it was found by many meta-analysis studies that the treatment of OAB with anticholinergics (antimuscarinic) can have a lack of benefit in up to 60% of cases.
Neuromodulation is one of methods that are used for treatment of overactive bladder. There are different types of neuromodulation includes: SNM, Pudendal Neuromodulation, and Percutaneous tibial nerve stimulation. The precise mechanism of action of electrical neuromodulation is still not entirely clear. However, a number of theories have been proposed to help explain the effect of electrical neuromodulation
The percutaneous tibial nerve stimulation is safe with statistically significant improvements in patient's condition. PTNS is considered as a minimally invasive, office-based procedure that consists of stimulating the nerve. Adverse events associated with PTNS are reported as mild, transient and relatively uncommon at 1–2 %, including bruising or bleeding at needle site, tingling and mild pain. PTNS demonstrates superiority to sham for both objective voiding parameters and subjective patient assessments. Using varying definitions of success, PTNS has been reported to have a 60% to 81% response rate in managed cases by this method.
PTNS appears to be effective in the management of severe OAB especially associated with neurologic conditions such as in cases with multiple sclerosis and Parkinsonian disease, without compromising bladder emptying or inducing side effect. PTNS has been used in children with OAB in whom behavioral and pharmacologic therapy fails.
It was found statistically that there is significant overactive bladder symptom improvement achieved with 12 weekly percutaneous tibial nerve stimulation treatments, followed by a 14-week prescribed tapering protocol and a personalized treatment plan with an average of 1.3 session of treatment per month. PTNS therapy for OAB demonstrates excellent durability through 12 months. Sustained safety and efficacy of PTNS were demonstrated over 24 months up to 36 months.
Excluding psychological reasons, generally, bladder over activity results either in absence of any associated other pathology affecting urinary tract according to Abrams and his colleges definition in 2002 or from abnormality either secondary to anatomical abnormalities, histological abnormal changes, neurological abnormalities or a combination as other authors believe in.
Overactivity of the detrusor muscle may be due to neurogenic, myogenic or idiopathic, and all of the previously mentioned subtypes of DO can result in urgency or urge incontinence, depending on the response of the internal urethral sphincter. Also disturbing and insulting the normal urothelial lining of the urinary bladder, unmyelinated C sensory fibers activation and suburothelial ICC-like cells play an important role in pathogenesis of OAB and DO.
In neurogenic DO, a popular classification is based on the location of the neurologic lesion. In myogenic DO, the theory postulates that unstable increase in intravesical pressure during involuntary detrusor contraction may result in periodic ischemia of bladder, resulting in damage to some intrinsic neurons in the bladder wall and secondary changes in the smooth muscle properties.
There are many conditions and diseases, which could cause LUTD such as BPE, OAB, UTI, and etc…. And they are characterized by presence of common symptoms such as frequency, urgency and other LUTS that may cause intermixing and misdiagnosis of the case. For this reason, a careful medical assessment is a prerequisite for LUTD to determine the cause and to reach a proper treatment plan.
The assessment tools for LUTD generally and OAB especially includes careful medical history, an abdominal and pelvic examination including digital rectal examination or palpation of vagina DRE/PV, also neurological examination, Frequency-volume charts and voiding diaries, and laboratoryevaluation including different type of labs. especially urinalysis. Urinary tract imaging and urethrocystoscopy are useful in certain cases either in diagnosis of the cause or in detecting any complications.
Uroflowmetry and PVR serve as noninvasive screening tests for selecting patients who should undergo more sophisticated urodynamic studies and for evaluating treatment effect during follow-up. Uroflowmetry alone is insufficient for distinguishing detrusor muscle dysfunction or urinary outlet abnormalities. If the initial evaluation indicates patients with myogenic or neurogenic caused voiding dysfunction, complete urodynamics including videourodynamics should be performed.
The therapy for OAB can be divided into the following classes of treatment: conservative management, pharmacotherapy, and surgical therapy. Usually the conservative management of OAB is not enough alone and usually pharmacotherapy is needed depending mainly on antimuscarinic medications. But, unfortunately, it was found by many meta-analysis studies that the treatment of OAB with anticholinergics (antimuscarinic) can have a lack of benefit in up to 60% of cases.
Neuromodulation is one of methods that are used for treatment of overactive bladder. There are different types of neuromodulation includes: SNM, Pudendal Neuromodulation, and Percutaneous tibial nerve stimulation. The precise mechanism of action of electrical neuromodulation is still not entirely clear. However, a number of theories have been proposed to help explain the effect of electrical neuromodulation
The percutaneous tibial nerve stimulation is safe with statistically significant improvements in patient's condition. PTNS is considered as a minimally invasive, office-based procedure that consists of stimulating the nerve. Adverse events associated with PTNS are reported as mild, transient and relatively uncommon at 1–2 %, including bruising or bleeding at needle site, tingling and mild pain. PTNS demonstrates superiority to sham for both objective voiding parameters and subjective patient assessments. Using varying definitions of success, PTNS has been reported to have a 60% to 81% response rate in managed cases by this method.
PTNS appears to be effective in the management of severe OAB especially associated with neurologic conditions such as in cases with multiple sclerosis and Parkinsonian disease, without compromising bladder emptying or inducing side effect. PTNS has been used in children with OAB in whom behavioral and pharmacologic therapy fails.
It was found statistically that there is significant overactive bladder symptom improvement achieved with 12 weekly percutaneous tibial nerve stimulation treatments, followed by a 14-week prescribed tapering protocol and a personalized treatment plan with an average of 1.3 session of treatment per month. PTNS therapy for OAB demonstrates excellent durability through 12 months. Sustained safety and efficacy of PTNS were demonstrated over 24 months up to 36 months.
Other data
| Title | REVIEW OF THE ROLE OF PERCUTANEOUS TIBIAL NERVE STIMULATION IN THE TREATMENT OF OVER ACTIVE BLADDER | Other Titles | عــرض لـدور تـحـفـيـز الـعـصـب الـظـنـبوبـي عــبـر الـجـلـد فـي عــلاج مـثـانـة زائـدة الـنـشاط | Authors | Mohammad Ibrahim Abd Eltawab | Issue Date | 2014 |
Recommend this item
Similar Items from Core Recommender Database
Items in Ain Shams Scholar are protected by copyright, with all rights reserved, unless otherwise indicated.