Effects of Posterior Tibial Nerve Stimulation on Fecal Incontinence: An Umbrella Review.

PURPOSE: This study aimed to summarize relevant data from previous systematic reviews (SRs) and conduct comprehensive research on the clinical effects of posterior tibial nerve stimulation (PTNS), via the transcutaneous posterior tibial nerve stimulation (TPTNS) or percutaneous posterior tibial nerve stimulation (PPTNS) method on fecal incontinence (FI). MATERIALS AND METHODS: In adherence to the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines, a systematic search was conducted on PubMed, Embase, Scopus, and Web of Science databases. We included English-language, full-text SRs reporting outcomes for FI following either PPTNS or TPTNS. The quality of included studies was assessed using the Joanna Briggs Institute checklist. In addition, reanalyzing the meta-analyses was conducted using Comprehensive Meta-Analysis (CMA) software version 3.0 to achieve effect sizes and the level of statistical significance was set at p ≤ 0.05. RESULTS: From a total of 835 citations, 14 SRs met our inclusion criteria. Four of these also conducted a meta-analysis. Most SRs reported an overall improvement in different study parameters, including bowel habits and quality of life. However, there were major inconsistencies across the results. The most studied outcome was FI episodes, followed by incontinence score. The summary outcomes showed no statistically significant changes in comparing PTNS with sham or sacral nerve stimulation (SNS) for FI (p > 0.05). However, the results of subgroup analysis based on the type of intervention in the control group revealed that FI episodes were significantly fewer than in the PTNS arm, whereas PTNS led to fewer episodes of FI than did the sham. In terms of incontinence score, the results showed that PTNS compared with sham did not change the incontinence score; however, SNS improved the score significantly in one eligible study for reanalysis when compared with PTNS (p < 0.001). CONCLUSIONS: The findings of the current umbrella review suggest that PTNS can potentially benefit patients with FI. However, this is concluded from studies with a limited population, disregarding the etiology of FI and with limited follow-up duration. Therefore, caution must be taken in contemplating the results.

Effects of posterior tibial nerve stimulation (PTNS) on lower urinary tract dysfunction: An umbrella review.

BACKGROUND: Lower urinary tract dysfunction (LUTD) is a common, troublesome condition that often negatively affects patients' quality of life. Current literature has long been interested in how posterior tibial nerve stimulation (PTNS) can affect this condition. AIM: To extensively and systematically explore how PTNS affects LUTD based on the most recent systematic reviews. METHODS: A systematic search was conducted in PubMed, Scopus, Web of Science, and Embase according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. All the systematic reviews, with or without meta-analysis that assessed the effects of PTNS on LUTD were retrieved. The quality of the included studies was assessed using the Joanna Briggs Institute tool, and analysis was conducted using the Comprehensive Meta-Analysis version 3 tool. RESULTS: From a total of 3077 citations, 20 systematic reviews entered this study, and 13 of them included meta-analysis. The population of studies varied vastly, for instance, some studies included only children or women while other focused on a specific pathology like multiple sclerosis-induced neurogenic LUTD. The majority of included studies reported an overall improvement in LUTD following percutaneous PTNS, although admitting that these results were derived from moderate to low-quality evidence. CONCLUSION: The findings of this thorough umbrella review showed that the positive benefits of PTNS in treating LUTD are currently supported by low-quality evidence, and it is crucial to interpret them with great care.

Efficacy of Tibial Nerve Stimulation in Neurogenic Lower Urinary Tract Dysfunction Among Patients with Multiple Sclerosis: A Systematic Review and Meta-analysis.

OBJECTIVE: This study was performed to systematically review the current literature on the effects of transcutaneous tibial nerve stimulation and percutaneous tibial nerve stimulation on multiple sclerosis-induced neurogenic lower urinary tract dysfunction. MATERIALS AND METHODS: Medical databases including PubMed, Scopus, Embase, and Web of Science were systematically searched from inception to September 2022. Metaanalysis was carried out using the comprehensive meta-analysis tool. RESULTS: Our inclusion criteria were met by 12 studies evaluating the effects of percutaneous tibial nerve stimulation/transcutaneous tibial nerve stimulation on multiple sclerosis-induced neurogenic lower urinary tract dysfunction. Comparing the postintervention results to the baseline showed that the rate of frequency was decreased in both percutaneous tibial nerve stimulation and transcutaneous tibial nerve stimulation groups after intervention. The overall mean change of tibial nerve stimulation on frequency was -2.623 (95% CI: -3.58, -1.66; P < .001, I 2 : 87.04) among 6 eligible studies. The post-void residual was decreased after treatment in both methods of tibial nerve stimulation, with an overall mean difference of -31.13 mL (95% CI: -50.62, -11.63; P=.002, I 2 : 71.81). The other urinary parameters, including urgency (mean difference: -4.69; 95% CI: -7.64, -1.74; P < .001, I 2 : 92.16), maximum cystometric capacity (mean difference: 70.95; 95% CI: 44.69, 97.21; P < .001, I 2 : 89.04), and nocturia (mean difference: -1.41; 95% CI: -2.22, 0.60; P < .001, I 2 : 95.15), were improved after intervention, too. However, the results of subgroup analysis showed no effect of transcutaneous tibial nerve stimulation on urinary incontinence (mean difference: -2.00; 95% CI: -4.06, 0.06; P=.057, I 2 : 95.22) and nocturia (mean difference: -0.39; 95% CI: -1.15, 0.37; P=.315, I 2 : 84.01). In terms of mean voided volume, the evidence was related to only percutaneous tibial nerve stimulation with a mean change of 75.01 mL (95% CI: -39.40, 110.61; P < .001, I 2 : 85.04). CONCLUSION: Although the current literature suggests that tibial nerve electrostimulation might be an effective method for treating neurogenic lower urinary tract dysfunction, the evidence base is poor and derived from small, mostly nonrandomized trials with a high risk of bias and confounding.

Is sacral neuromodulation effective and safe in pregnancy? A systematic review.

OBJECTIVE: We systematically assessed all available evidence on the efficacy and safety of sacral neuromodulation (SNM) in pregnancy. METHODS: On September 2022, a thorough search was done on Ovid, PubMed, Scopus, ProQuest, Web of Science, and The Cochrane Library. We chose studies that included pregnant women who had SNM previously. Two authors independently evaluated the quality of the study using a standardized tool of JBI. Studies were given a risk of bias rating of low, moderate, or high. Given the descriptive nature of this study, we utilized descriptive statistics to report demographic and clinical features. For continuous variables, we used mean and standard deviation, and for dichotomous data, we used frequencies and percentages. RESULTS: Out of 991 abstracts screened, only 14 studies met our inclusion criteria and were included in the review. Overall, the quality of the evidence available from the literature is low based on the design of the included studies. Fifty-eight women, including 72 pregnancies, had SNM. The indication of SNM implantation was filling phase disorders in 18 cases (30.5%), voiding dysfunction in 35 women (59.3%), IC/BPS in two cases (3.5%), and fecal incontinence. In 38 pregnancies (58.5%), the SNM status was ON during pregnancy. Forty-nine cases delivered a full-term baby (75.4%), 12 cases had pre-term labor (18.5%), two miscarriages, and two postterm pregnancies happened. The most complications in patients with devices were urinary tract infection in 15 women (23.8%), urinary retention in six patients (9.5%), and pyelonephritis in two cases (3.2%). The findings revealed that when the device was deactivated, 11 cases out of the 23 patients (47.8%) had full-term pregnancies, while in ON status, 35 out of the 38 pregnant women (92.1%) had full-term pregnancies. Nine preterm labors in OFF (39.1%), and two in ON status (5.3%) were recorded. The results revealed that this difference was statistically significant (p = 0.002), and those who turned SNM of them off had more preterm labor. Although the studies reported all neonates had a healthy status, two children had chronic motor tic problems and a pilonidal sinus in a case with an active SNM in pregnancy. However, there was no association between the SNM status and pregnancy or neonatal complications (p = 0.057). CONCLUSION: SNM activation in pregnancy seems safe and effective. The choice of whether to activate or deactivate SNM should be made on an individual basis given the current SNM evidence.

Sacral neuromodulation in patients with detrusor underactivity: Is biological sex an indicator?

OBJECTIVES: This study aimed to report sacral neuromodulation (SNM) outcomes in detrusor underactivity (DU). METHODS: A multicentric, multinational, retrospective case series was conducted between March 2017 and June 2021 in three different referral centers. Initial test phase stimulation included either a percutaneous nerve evaluation (PNE) or an advanced lead evaluation test phase (ALTP) before permanent SNM implantation. The test phases were performed under local anesthesia, either in the outpatient (PNE) or operating room (ALTP), in the prone position, which was implanted in the third or fourth sacral foramina under fluoroscopic guidance. Patients with favorable response to the initial test phase during the first 2 weeks underwent the implantable pulse generator (IPG) implantation (Medtronic neurostimulation generator device InterStim™). Favorable response was defined as ≥ 50% improvement in symptoms, frequency of clean intermittent catheterization (CIC) and/or decrease in postvoid residual (PVR), increase in voided volume, or improvement in bladder voiding efficiency (BVE) based on the bladder diary. RESULTS: Fifty-eight patients were recruited with a mean age of 39.95 ± 15.28 years. Among the 58 cases, 36 (62.1%) patients responded to the initial stage. Of these, 12 patients (30.8%) with non-neurogenic etiology and nine patients (52.9%) with neurologic etiology did not respond to the initial test phase; thus, they did not undergo full implantation (p = 0.141). Voided volume, PVR, and the median maximum flow rate (Qmax) improved significantly (p < 0.001) in both sexes; however, there was no statistical difference between both genders. Most female cases (78.3%), and nearly half of the men (51.4%), responded to the test phase and were candidates for the IPG phase. Among the 35 cases who underwent IPG, 27 patients (72.2% of males, and 77.8% of females; p = 0.700) had a favorable response to IPG. 46.6% of patients had a successful outcome at the end of the study. CONCLUSION: This multicentric study showed that SNM effectively and safely provided symptom improvement in refractory DU in males similar to females which is an important finding as previously it has been suggested that SNM works better in nonobstructive urinary retention in women and not in women.

Efficacy of percutaneous and transcutaneous posterior tibial nerve stimulation on idiopathic overactive bladder and interstitial cystitis/painful bladder syndrome: A systematic review and meta-analysis.

OBJECTIVES: Percutaneous and transcutaneous posterior tibial nerve stimulation (PTNS and TTNS) showed a promising effect on overactive bladder (OAB) and interstitial cystitis/painful bladder syndrome. We aimed to give a systematic review and meta-analysis on the efficacy and safety of these therapeutic methods as well. METHODS: We searched studies available on PubMed, Embase, Cochrane, Scopus, Web of Science, and ProQuest on March 31, 2021, to find both published and unpublished studies. The retrieved articles were screened by two independent researchers and then the selected studies were critically appraised by Cochrane risk-of-bias tool for randomized trials, and Joanna Briggs Institute's checklist for quasi-experimental studies. Finally, the results of studies were synthesized using Review Manager (RevMan) 5.4 statistical software when the data were homogenous. The meta-analysis was performed by calculating the effect size (mean difference) and their 95% confidence intervals (CIs). RESULTS: Of the total 3194 publications, 68 studies were included in our qualitative evaluation and 9 studies (11 trials) in the quantitative stage. When TTNS or PTNS were compared to sham, placebo, no treatment, or conservative management, a decrease in frequency of urination was observed in both TTNS (mean difference [MD]: -3.18, 95% CI: -4.42 to -1.94, and p < 0.00001), and PTNS (MD: -2.84, 95% CI: -4.22 to -1.45, and p < 0.00001), and overall TTNS or PTNS (MD: -2.95, 95% CI: -4.01 to -1.88, and p < 0.00001). Significant improvements in mean voiding volume (MVV) and decreasing nocturia were also observed. CONCLUSIONS: Nerve stimulations either PTNS or TTNS appear to be effective interventions in treating refractory idiopathic OAB in terms of daily voiding frequency, MVV, urgency episodes, and nighttime voiding frequency. However, our result did not show any improvement in terms of urinary incontinence, postvoid residual volume or urge incontinence, and maximum cystometric capacity which emphasized the efficacy of these modalities on dry-OAB rather than wet-OAB.

Transvaginal repair of anterior vaginal wall prolapse with polyvinylidene fluoride (PVDF) mesh: an alternative for previously restricted materials?

INTRODUCTION AND HYPOTHESIS: To study the mid-term safety and functional outcomes of transvaginal anterior vaginal wall prolapse repair using polyvinylidene fluoride (PVDF) mesh (DynaMesh®-PR4) by the double trans-obturator technique (TOT). METHODS: Between 2015 and 2020, we prospectively included women with symptomatic high-stage anterior vaginal wall prolapse with or without uterine prolapse or stress urinary incontinence (SUI) in the study. The patients underwent transvaginal repair of the prolapse using PVDF mesh in two medical centers. We followed all patients for at least 12 months. We recorded the characteristics of vaginal and sexual symptoms, urinary incontinence, and prolapse stage pre- and postoperatively using International Consultation on Incontinence Questionnaire-Vaginal Symptoms (ICIQ-VS), International Consultation on Incontinence Questionnaire-Urinary Incontinence-Short Form (ICIQ-UI-SF), and Pelvic Organ Prolapse Quantification (POP-Q) system, respectively. RESULTS: One hundred eight women were included in the final analysis with a mean follow-up time of 34.5 ± 18.6 months. The anatomical success was achieved in 103 (95.4%) patients. There was a significant improvement in patients' vaginal symptoms, urinary incontinence, and quality of life scores postoperatively (p < 0.0001). Only six patients (5.5%) had mesh extrusion, five of whom were managed successfully. The total rates of complications and de novo urinary symptoms were 21.3% and 7.4%, respectively. Significant pain was reported in 17 cases (15.7%). CONCLUSION: Our findings show that using PVDF mesh in the double TOT technique for anterior vaginal wall prolapse repair is a safe procedure with high anatomic and functional success rates and acceptable complication rates in mid-term follow-up.

Using Ozone Therapy as an Option for Treatment of COVID-19 Patients: A Scoping Review.

Recent investigations are seeking a novel treatment to control the new pandemic of coronavirus 19 (COVID-19). The aim of this systematic review was to study the effect of ozone therapy on COVID-19 patients and the available supporting evidence. Electronic databases including MEDLINE (via PubMed), EMBASE, Cochrane Library (CENTRAL), and TRIP, clinical trial registries, and preprint sources were searched for published evidence-based articles. In addition, manual searching was conducted for articles published up to April 6, 2020, using MeSH and free text keywords with no language limitation. Articles were screened, categorized, and extracted for relative data. Data were reported in a descriptive manner. Among 234 articles, 9 were selected for review of the inclusion criteria. No published original articles were found regarding the efficacy of ozone therapy on COVID-19. Five review studies were found in which the potential role of systemic ozone therapy was concluded to be effective in controlling COVID-19 because of its antiviral, oxygenation, anti-inflammatory, oxidation balancing, and immunomodulation effects. Three ongoing clinical trials were registered in China. A preliminary report of an ongoing study in Italy on 46 patients (11 intubated and 35 non-intubated) showed that in 39 (84%) of the patients, an improvement was seen. In spite of the promising background data, as well as the expert opinions and a preliminary report indicating the effectiveness of ozone, there is still not enough evidence to confirm this as a viable treatment option for COVID-19.

A Systematic Review and Meta-Analysis: The Effectiveness of Probiotics for Viral Gastroenteritis.

BACKGROUND: Probiotics can be used for the treatment of viral gastroenteritis. OBJECTIVE: This systematic review is to evaluate the evidence regarding the effect of probiotics on human cases of viral gastroenteritis. METHODS: The objective of this review is to evaluate the effectiveness of probiotics against placebo or standard treatment for viral gastroenteritis. A comprehensive search of Cochrane Library, EMBASE, MEDLINE via PubMed and Ovid databases, and unpublished studies (till 27 January 2018) was conducted followed by a process of study selection and critical appraisal by two independent reviewers. Randomized controlled trials assessing probiotic administration in human subjects infected with any species of gastroenteritis viruses were considered for inclusion. Only studies with a confirmed viral cause of infection were included. This study was developed using the JBI methodology for systematic reviews, which is in accordance with the PRISMA guideline. Meta-analysis was conducted where feasible. Data were pooled using the inverse variance method with random effects models and expressed as Mean Differences (MDs) with 95% Confidence Intervals (CIs). Heterogeneity was assessed by Cochran Q statistic and quantified by the I2 statistic. We included 17 RCTs, containing 3,082 patients. RESULTS: Probiotics can improve symptoms of viral gastroenteritis, including the duration of diarrhea (mean difference 0.7 days, 95% CI 0.31 to 1.09 days, n = 740, ten trials) and duration of hospitalization (mean difference 0.76 days, 95% CI 0.61 to 0.92 days, n = 329, four trials). CONCLUSION: The results of this review show that the administration of probiotics in patients with viral gastroenteritis should be considered.

Pelvic floor rehabilitation in the treatment of women with dyspareunia: a randomized controlled clinical trial.

INTRODUCTION AND HYPOTHESIS: Dyspareunia, the symptom of painful sexual intercourse, is a common sexual dysfunction in reproductive-aged women. Because of its multifactorial etiology, a multidisciplinary approach may be required to treat it. Musculoskeletal factors play an important role; thus, rehabilitating the pelvic floor and modifying the tone of the pelvic floor muscles (PFMs) may be an effective way to treat this dysfunction. The aim of this randomized controlled clinical study was to evaluate the effects of pelvic floor rehabilitation techniques on dyspareunia. METHODS: Of 84 women, assessed for eligibility, 64 women with dyspareunia were randomized into two groups: the experimental group (n = 32) received electrotherapy, manual therapy, and PFM exercises and the control group (n = 32) had no treatment while on the waiting list. Evaluations of PFM strength and endurance, sexual function, and pain were made directly before and after 3 months of treatment and at the 3-month follow-up. RESULTS: Between-group changes showed significant improvement in the experimental group in comparison with control group. Mean difference in the PFM strength (according to the 0-5 Oxford scale) between groups was 2.01 and the mean difference of endurance was 6.26 s. Also, the mean difference in the Female Sexual Function Index score (the score ranges from 2 to 95) was 51.05, and the mean difference in the VAS score was 7.32. All of the changes were statistically significant (p < 0.05). CONCLUSIONS: According to the results, pelvic floor rehabilitation is an important part of a multidisciplinary treatment approach to dyspareunia.