Transcutaneous tibial nerve stimulation in patients with multiple sclerosis and overactive bladder: a real-life clinical and urodynamic assessment.

AIMS: The aims of the present study were to assess the effectiveness of transcutaneous tibial nerve stimulation (TTNS) on overactive bladder (OAB) symptoms and on urodynamic parameters in patients with multiple sclerosis (PwMS) and to seek predictive factors of satisfaction. METHODS: All PwMS who performed 12-24 weeks of TTNS and who underwent urodynamic assessment before and after treatment between June 2020 and October 2022 were included retrospectively. Data collected were bladder diaries, symptoms assessed with Urinary Symptoms Profile (USP), and urodynamic parameters (bladder sensations, detrusor overactivity, and voiding phase). Patients with improvement rated as very good or good on Patient Global Impression of Improvement (PGI-I) score were considered as responders. RESULTS: Eighty-two patients were included (mean age: 47.1 ± 11.5 years, 67 (82%) were women). The mean USP OAB sub-score decreased from 7.7 ± 3.5 to 6.0 ± 3.4 (p < 0.0001). On bladder diaries, voided volumes, void frequency, and the proportion of micturition done at urgent need to void significantly improved with TTNS (p < 0.05). No significant change was found in urodynamic parameters. According to the PGI-I, 34 (42.5%) patients were good responders. The only parameter associated with higher satisfaction was the percentage of micturition done at urgent need to void before the initiation of the treatment (39.8% ± 30.5 in the responder group vs 25.1% ± 25.6 in the low/no responder group; p = 0.04). CONCLUSION: TTNS improves OAB symptoms in PwMS, without significant changes on urodynamics. A high rate of strong or urgent need to void in daily life was associated with higher satisfaction.

Cortical, Spinal, Sacral, and Peripheral Neuromodulations as Therapeutic Approaches for the Treatment of Lower Urinary Tract Symptoms in Multiple Sclerosis Patients: A Review.

INTRODUCTION: Multiple sclerosis (MS) is often associated with urological disorders, mainly urinary incontinence and retention, the management of which being necessary to improve patient's quality of life (QOL) and to reduce potential urological complications. Besides the classical treatments based mainly on anticholinergics and/or self-catheterization, several neuromodulation techniques have been tried in recent years to improve these urinary disorders. By this review, we aim at providing an overview of neuromodulation and electrostimulation approaches to manage urinary symptoms in MS patients. MATERIALS AND METHODS: A literature search using MEDLINE was performed. Only papers in English, and describing the effects of neuromodulation in MS patients, were considered. RESULTS: A total of 18 studies met inclusion criteria and were reviewed. Of them, four related to sacral neuromodulation (SNM), seven to percutaneous tibial nerve stimulation (PTNS), six to spinal cord stimulation (SCS), and one to transcranial magnetic stimulation (TMS). DISCUSSION: PTNS and SNM seem to be effective and safe therapeutic options for treating lower urinary tract symptoms in MS patients principally in case of overactive bladder (OAB) symptoms. Similarly, also SCS and TMS have been shown to be effective, despite the very limited number of patients and the small number of studies found in the literature. Interestingly, these techniques are effective even in patients who do not respond well to conservative therapies, such as anticholinergics. Furthermore, given their safety and efficacy, stimulations such as PTNS could be considered as a first-line treatment for OAB in MS patients, also considering that they are often preferred by patients to other commonly used treatments.

Contribution of sacral neuromodulation to manage persistent voiding dysfunction after surgery for deep infiltrating endometriosis with colorectal involvement: preliminary results.

OBJECTIVE: Around 5% of women experience persistent voiding dysfunction after surgery for deep infiltrating endometriosis (DIE) with colorectal involvement. The gold standard to manage persistent voiding dysfunction is intermittent self-catherization, but this treatment may reduce quality of life of the patients due to care constraints. The objective of our study was to assess the contribution of sacral neuromodulation (SNM) in the management of persistent voiding dysfunction secondary to surgery for DIE with colorectal resection. STUDY DESIGN: Five patients referred for persistent voiding dysfunction after surgery for DIE with colorectal resection were included and fitted with a temporary SNM system to test for feasibility. This consisted of placing an electrode unilaterally next to the S3 sacral nerve root and connecting it to an external pacemaker. The patients wore the electrode and the external neurostimulator for 21 days and kept a voiding diary. The SNM test was considered positive when a 50% decrease in self-catheterization was achieved after removal of the electrode. The system was implanted permanently in patients with a positive SNM test. Urodynamic tests were performed before and after the SNM test. RESULTS: Two of the five patients had a positive SNM test and were implanted permanently. At 40 months the first patient had completely stopped self-catheterization and the second patient was performing self-catheterization twice a day with a post voiding residue volume of less than 100ml at 52 months. CONCLUSION: SNM could be a curative technique in some patients with persistent voiding dysfunction after surgery for DIE. Further studies are required to better select patients who might benefit from SNM testing and subsequent device implantation.

Influence of a distraction task on pelvic floor muscle contraction.

AIMS: Attention may play a key role in the contraction of pelvic floor muscles in stressful situations, meaning that mental distraction may be involved in urinary incontinence. METHODS: Informed consent was obtained from 20 healthy volunteers. The electromyographic (EMG) activity of the external anal sphincter (EAS) was recorded during voluntary contraction elicited by local stimulation. The trials were carried out twice: combined (or not) with a mental distraction task (PASAT), Paced auditory serial additional test. Reaction time, latency between the stimulus and maximum EAS EMG activity, duration of the contraction, maximum EAS EMG activity, and the area under the EAS EMG activity curve were measured. RESULTS: The mental distraction task led to a 3.98 times greater reaction time (RT), (P = 0.00001 Wilcoxon's test). The RT increased from 217 (IQR: 170-270) to 779 msec (IQR: 550-1,025, P < 0.0001) when the EAS contraction was combined with PASAT. However, the maximum EAS EMG activity was weaker during PASAT than in the absence of a mental distraction task: 0.0850 mv versus 0.0701 mv, that is, 1.21 times weaker (P = 0.00077, Wilcoxon's test). Finally, when the two conditions (respectively with and without the mental distraction task) were compared, no significant difference was found in the area under the EAS EMG activity curve (0.0157 mv sec vs. 0.0162 mv sec, ratio 1.01, P = 0.52). CONCLUSIONS: The mental distraction task altered voluntary contraction of the pelvic floor muscles.

Cranberry versus placebo in the prevention of urinary infections in multiple sclerosis: a multicenter, randomized, placebo-controlled, double-blind trial.

OBJECTIVE: Our aim was to assess the usefulness of cranberry extract in multiple sclerosis (MS) patients suffering from urinary disorders. METHODS: In total, 171 adult MS outpatients with urinary disorders presenting at eight centers were randomized (stratification according to center and use of clean intermittent self-catheterization) to cranberry versus placebo in a 1-year, prospective, double-blind study that was analyzed using a sequential method on an intent-to-treat basis. An independent monitoring board analyzed the results of the analyses each time 40 patients were assessed on the main endpoint. Cranberry extract (36 mg proanthocyanidins per day) or a matching placebo was taken by participants twice daily for 1 year. The primary endpoint was the time to first symptomatic urinary tract infection (UTI), subject to validation by a validation committee. RESULTS: The second sequential analyses allowed us to accept the null hypothesis (no difference between cranberry and placebo). There was no difference in time to first symptomatic UTI distribution across 1 year, with an estimated hazard ratio of 0.99, 95% CI [0.61, 1.60] (p = 0.97). Secondary endpoints and tolerance did not differ between groups. CONCLUSION: Taking cranberry extract versus placebo twice a day did not prevent UTI occurrence in MS patients with urinary disorders. Trial Registration NCT00280592.

[Conservative treatment of female urinary incontinence]. / Traitements conservateurs de l'incontinence urinaire de la femme.

Female urinary incontinence can be improved by nonsurgical pharmacologic as well as non-pharmacologic treatments. Hygiene and dietary rules apply to all forms of incontinence. If overweight, weight loss improves stress urinary incontinence. There are levels of evidence to show that pelvic floor muscle training and behavioral therapy improve incontinence. Duloxetine is better than placebo for improvement of quality of life and for the impression of an improvement, but its place is still not determined in the algorithm of conservative treatments. The effects of vaginal electrostimulation and oestrogen are inconsistent or inhomogeneous. In case of urgency incontinence, anticholinergics remain the first line treatment and the place of stimulation of posterieur tibial nerve is still to be defined.

Transcutaneous posterior tibial nerve stimulation for treatment of the overactive bladder syndrome in multiple sclerosis: results of a multicenter prospective study.

AIMS: Electrostimulation is an established therapeutic option for neurogenic urinary disorders. The aim of this study was to investigate the efficacy of the noninvasive technique of transcutaneous posterior tibial nerve stimulation (TPTNS) in patients with multiple sclerosis (MS) and troublesome symptoms of an overactive bladder (OAB). METHODS: A multicentric study enrolled 70 MS patients, suffering from OAB for a 3-month study period. INTERVENTION: Daily sessions of 20 min of TPTNS were provided. No change of associated treatments during the study period. The primary outcome measurement was Urgency and Frequency reported by bladder diary and symptom score performed before the treatment (Day 0, D0) and at D30 and D90. The secondary outcomes measurements were continence, symptom score, quality of life, psychosocial burden at DO, D30, and D90 and cystometry at baseline, with and without TPTNS and at D90. RESULTS: Clinical improvement of OAB was shown in 82.6% and 83.3% of the patients on D30 and D90, respectively, with significant improvement of primary and secondary outcomes compared to baseline. The initial acute cystometric response to TPTNS was positive in 51.2% of the patients (increase of >30% of cystometric capacity and/or reflex volume), without correlation with TPTNS clinical efficiency. The procedure was well tolerated. CONCLUSIONS: Chronic TPTNS appears to be effective in the management of severe OAB in MS, without compromising bladder emptying or inducing side effect. Treatment may be effective even in the absence of an acute cystometric effect. Additional works are required to demonstrate long-term efficacy of TPTNS.