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Transcutaneous stimulation of the posterior tibial nerve for treating refractory urge incontinence of idiopathic and neurogenic origin
Estimulación transcutánea del nervio tibial posterior en el tratamiento de la incontinencia urinaria de urgencia refractaria, de origen idiopático y neurógenico
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Valles-Antuña, M.L. Pérez-Haro, C. González-Ruiz de León, A. Quintás-Blanco, E.M. Tamargo-Diaz, J. García-Rodríguez, A. San Martín-Blanco, J.M. Fernandez-Gomez" "autores" => array:8 [ 0 => array:3 [ "nombre" => "C." "apellidos" => "Valles-Antuña" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 1 => array:4 [ "nombre" => "M.L." "apellidos" => "Pérez-Haro" "email" => array:1 [ 0 => "llanosph@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 2 => array:3 [ "nombre" => "C." "apellidos" => "González-Ruiz de León" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "A." 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"apellidos" => "Fernandez-Gomez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Neurofisiología, Hospital Universitario Central de Asturias, Oviedo, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Urología, Hospital Universitario Central de Asturias, Oviedo, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Estimulación transcutánea del nervio tibial posterior en el tratamiento de la incontinencia urinaria de urgencia refractaria, de origen idiopático y neurógenico" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 965 "Ancho" => 900 "Tamanyo" => 127692 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Placement of the electrodes for transcutaneous stimulation of the posterior tibial nerve. The black (proximal) electrode corresponds to the active, the red one to the reference, and the green one to the earth wire (safety).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The prevalence of urge urinary incontinence (UUI) is increasing and is high in both women and men, particularly in adults over 40 years of age. In large-scale studies, the prevalence of UUI varies in adults aged 18–20 years, ranging from 1.5% to 14.3% for men, and between 1.6% and 22.8% for women, whereas in studies of adults aged 30–40 years the prevalence ranges from 1.7% to 13.3% for males and from 7% to 30.3% for females.<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">1</span></a> The prevalence of overactive bladder syndrome (OAB) in Spain is around 16% and in Europe between 12% and 22%.<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Urinary urgency and associated incontinence have a negative impact on quality of life. Studies estimating the economic burden of the UUI indicate that it is an important problem and will increase in the future with the aging of the population.<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">1</span></a> Therefore, there are obvious reasons for treating UUI, especially if there are comorbidities such as neurological diseases, mobility deficits, diabetes or pelvic organ disorders.<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">3</span></a> Conventional treatment with general measures, bladder training and first-line pharmacological treatment do not always manage to control symptoms. In addition, there are drop-outs due to side effects. Botulinum toxin has demonstrated its efficacy in neurogenic or idiopathic detrusor overactivity in cases in which conservative and medical treatment has failed, is not tolerated, or there is contraindication to its use.<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">4</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">When the above strategies are not effective, or the side effects prevent the use of botulinum toxin, it is possible to offer electrical neuromodulation of the sacral roots or the posterior tibial nerve. Sacral neuromodulation has historically been applied by a surgically implanted electrode at the S3 level. Stimulation of the posterior tibial nerve offers a less invasive alternative, with the same mechanism of action as direct neuromodulation of the sacral roots.<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">5</span></a> Stimuli can be applied by using a monopolar needle inserted near the nerve (percutaneous posterior tibial nerve stimulation [P-PTNS]) or, more recently, by superficial skin electrodes (transcutaneous posterior tibial nerve stimulation [T-PTNS]). In this sense, McGuire et al. have demonstrated that it is possible to inhibit overactive detrusor with transcutaneous stimulation of the common peroneal or posterior tibial nerve (T-PTNS).<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">6</span></a> Although several studies have demonstrated the efficacy of P-PTNS for the treatment of OAB, the effectiveness of transcutaneous stimulation has been poorly evaluated,<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">7</span></a> being a treatment that can be applied on an outpatient basis and with minimal discomfort for the patient. The aim of this study is to evaluate the efficacy of treatment with T-PTNS in patients with UUI, of neurogenic or non-neurogenic origin and refractory to the first-line therapeutic options.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Materials and methods</span><p id="par0020" class="elsevierStylePara elsevierViewall">We designed a prospective cohort study, including 65 patients with UUI as the main symptom, which have not improved significantly after being treated with antimuscarinic drugs. The study included 41 women and 24 men (mean age 55.06 years, 26–80 years). The anamnesis included a general and specific history focused on the past and present of symptoms and disorders of the urinary tract and neurological function. Before starting T-PTNS, an urodynamic study was performed in all patients in order to detect detrusor overactivity. To assess baseline clinical status, each patient completed a voiding diary for seven days, which included questions on daytime voiding frequency, night time urine production, urge incontinence episodes, and the number of compresses used daily. The same diary was filled out before and after the therapy. Subjective improvement or patient satisfaction at the end of therapy was evaluated by a single question, yes/no answer, on the overall improvement of urinary symptoms.</p><p id="par0025" class="elsevierStylePara elsevierViewall">The integrity of the somatic afferent pathways of the lower limb and the perineal zone was assessed by combining the somatosensory evoked potentials of the tibial and pudendal nerves. The treatment protocol consisted of 10 weekly sessions of 30<span class="elsevierStyleHsp" style=""></span>min duration. Transcutaneous stimulation was performed with surface electrodes placed at the ankle level over the posterior tibial nerve path (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). The proximity of the active electrode to the nerve was assured with neurographic control, assessing the intensity of the minimum stimulus necessary to evoke response in <span class="elsevierStyleItalic">adductor hallucis</span>, and choosing to apply the treatment to the side with the motor response of greater amplitude. Square pulses of 200<span class="elsevierStyleHsp" style=""></span>μs duration and frequency of 20<span class="elsevierStyleHsp" style=""></span>Hz were administered at not painful intensity and immediately below the motor threshold. Both the neurophysiological tests and the T-PTNS were performed with Synergy EMG/EP<span class="elsevierStyleSup">®</span> equipment.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">The analysis of continuous results was performed using non-parametric tests. Correlation tests were used to analyze linear relationships between two variables. For the categorical results, the groups were compared using the Chi square or Fisher test. The Wilcoxon test was applied for the paired analysis of the differences in the change of variables before and after treatment. Statistical analysis was performed with the SPSS 19.0 statistical software.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0040" class="elsevierStylePara elsevierViewall">A total of 65 patients were finally treated, 64 undergoing 10 sessions of stimulation (one woman did not complete the program due to an incident unrelated with the procedure). As shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>, there was a history of neurological disorder in 26 (40%) of the 65 patients, 21 (32.3%) of them with central nervous system disease and 5 (7.7%) with peripheral neuropathy, mostly radiculopathies. No significant differences were found by gender or age in relation to the positive history of neurological disorders.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">Taking into account the neurophysiological results, 57% of the patients showed alterations in the somatosensory evoked potentials of the posterior tibial nerve and 42% of the patients in the somatosensory evoked potentials of the pudendal nerve. A significant correlation (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.001) was found between the total conduction time of the evoked potentials of the posterior tibial nerve and pudendal. There was no correlation between measures of somatosensory evoked potentials and improvement in urological clinical after transcutaneous posterior tibial nerve stimulation or between somatosensory evoked potentials and history of neurological disorders.</p><p id="par0055" class="elsevierStylePara elsevierViewall">The baseline clinical assessment showed a mean of 8.2 times daytime voiding frequency and 2.5 times night time urine production, with a median of one (0–14) urinary incontinence episode per day and a median of one (0–6) compress used daily. After the ninth session of P-PTNS, we found a mean of 7.48<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>3.6 times in the daytime voiding frequency, and 1.03<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>2.16 times at night, with a median of 0.1 (0–12.4) episodes of urge incontinence episodes per day and a median of one (0–6) compress used per day. Statistically significant improvements were observed in all symptom scores of the cited variables (daytime and night time voiding frequency, incontinence episodes and number of compresses used per day). <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> summarizes the treatment results in relation to urinary symptoms and the relationship among the four variables cited.</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">Regarding patient satisfaction, 66% reported subjective improvement and 34% did not find any difference. Subjective improvement was independent of gender, history of neurological disorders, detrusor overactivity, and abnormalities in somatosensory evoked potentials. Among patients without subjective improvement, 27% (9.2% of the entire sample) showed clinical improvement in the voiding diary and only one patient did not achieve any improvement after tibial nerve stimulation. The decrease in the night urine production was the symptom that most responded in the group of patients who did not report good subjective results. No side effects were found with the application of T-PTNS in our series.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0065" class="elsevierStylePara elsevierViewall">Educational therapies combined with antimuscarinic drugs are the basic treatment of UUI. Antimuscarinic drugs may improve symptoms in some patients, but they also have side effects such as arrhythmias, dry mouth, dry eye, blurred vision, dyspepsia, UTI, or urine retention. Caution should be exercised when prescribing antimuscarinics in fragile patients, in patients with impaired cognition, and in patients using other anticholinergic therapies, or in whom acetylcholinesterase inhibitors have been prescribed. In practice, 50% of patients stop antimuscarinic therapy within the first three months due to lack of benefit,<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">8</span></a> side effects and cost.<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">9</span></a> Mirabegrin seems to have an efficacy similar to tolterodine, with fewer antimuscarinic effects, although it is not free from adverse effects such as hypertension, dry mouth, headache, influenza, constipation, dizziness, …<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">10</span></a> Botulinum toxin is currently recommended as a third line in the treatment of overactive bladder in Europe and the USA in selected patients refractory to drug therapy.<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">11</span></a> However, there are still doubts about the selection of suitable candidates, the type of anesthesia, the dose required, the mode of injection (trigone-body, sub-intratelial-intramuscular), injection points, dilution, reinjection efficiency and safety in the long term.<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">4</span></a> In addition, it is associated with an increased risk of acute urinary retention, urinary infections and the need for intermittent catheterization.<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">12</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">Neurostimulation of the roots of the sacral plexus through the posterior tibial nerve seems a logical choice before resorting to direct neuromodulation of the sacral root using invasive procedures. The mechanism of action of posterior tibial nerve stimulation is unclear. In cats it has shown an inhibitory effect on the activity of the detrusor that could significantly increase the capacity of the bladder.<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">13</span></a> Other possible places of action are ascending and descending pathways that connect with the brainstem and the brain centers of bladder control. In addition, activation of the afferent pathways causing inhibition at the spinal and supraspinal levels plays an important role in neuromodulation.<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">14,15</span></a> This technique was approved by the FDA in 2000 and consists of weekly sessions with the percutaneous insertion of needle-electrode stimulants above the internal malleolus.<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">16</span></a> A recent systematic review has shown that percutaneous posterior tibial nerve stimulation is effective in 54.5–79.5% of patients treated with overactive bladder.<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">17</span></a> All studies reviewed have demonstrated positive urodynamic or clinical results with this treatment.<a class="elsevierStyleCrossRefs" href="#bib0250"><span class="elsevierStyleSup">18–20</span></a> Therefore, current guidelines include, with different levels of recommendation, this technique in the conservative management of hyperactive bladder syndrome.<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">17,21,22</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">Transcutaneous posterior tibial nerve stimulation is a noninvasive technique that has barely been evaluated and is not fully standardized. Two studies have shown clinical improvement in women with OAB.<a class="elsevierStyleCrossRefs" href="#bib0265"><span class="elsevierStyleSup">21,23</span></a> In addition, Schreiner et al.<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">24</span></a> published a randomized clinical trial on its efficacy to treat urge incontinence in 51 women with UUI. All women were treated with 12 weeks of bladder training and pelvic floor exercises, and 25 were randomly selected for P-PTNS related. The group that was treated with transcutaneous posterior tibial nerve stimulation showed significant improvement compared to the control group.</p><p id="par0080" class="elsevierStylePara elsevierViewall">Our results have shown a significant clinical improvement for all the symptoms measured in the voiding diary, and positive subjective results in 66% of the patients. These data are similar to those of previous studies using the percutaneous stimulation technique, in which the percentage of patients with improvement ranges from 54% to 79.5%.<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">16</span></a> The positive response obtained in this study could be very related to the use of a protocol of stimulation guided by neurography and specifically designed to achieve the most effective nervous activation. The location of the active electrode and the stimulus intensity were individually adjusted by neurographic control at the beginning of each therapeutic session, this being particularly important in cases where an excess of subcutaneous tissue or edema could hinder optimum stimulation. Finally, we used pulse parameters similar to those found to be most effective for percutaneous posterior tibial nerve stimulation.</p><p id="par0085" class="elsevierStylePara elsevierViewall">Early trials of sacral neuromodulation excluded patients with neurogenic dysfunctions, as it was assumed that intact spinal pathways were required for neuromodulation. However, since FDA approval, there have been many reports on the use of sacral neuromodulation in the treatment of neurogenic bladder dysfunction.<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">25</span></a> The use of posterior tibial nerve stimulation in patients with neurogenic bladder has recently been evaluated, and the improvement in symptoms has been seen in patients with multiple sclerosis after P-PTNS<a class="elsevierStyleCrossRefs" href="#bib0290"><span class="elsevierStyleSup">26,27</span></a> and T-PTNS.<a class="elsevierStyleCrossRefs" href="#bib0300"><span class="elsevierStyleSup">28,29</span></a> In our study, we have obtained similar clinical improvement in patients with and without a history of neurological dysfunction. As patients with neurogenic substrate showed different types and levels of neurological alteration, we evaluated the integrity of lumbosacral somatosensory afferent pathways through somatosensory evoked potentials, finding that abnormal responses in the evoked potentials of pudendal and posterior tibial nerve had no influence on the therapeutic effects of tibial nerve stimulation. The influence of PTNS on small diameter nerve fibers (C and Aδ) may play a role in the therapeutic effect, regardless of the functional status of the myelinated thick fiber pathways.</p><p id="par0090" class="elsevierStylePara elsevierViewall">Among the limitations of our study, we should mention the lack of inclusion of validated questionnaires to evaluate clinical improvement, or a post-treatment urodynamic study, although clinical improvement is not always associated with urodynamic changes in these patients.<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">29</span></a> However, this study provides objective and easily comparable data showing the beneficial clinical effect of T-PTNS, with the number of urgency episodes being one of the most important.<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">30</span></a> In addition, our patients reported that nocturia was the symptom with the highest degree of subjective improvement, probably because it is the one that most affect their quality of life. This would also explain that the decrease in the day time voiding frequency was the most important improvement observed in the patients who did not report a good subjective result.</p><p id="par0095" class="elsevierStylePara elsevierViewall">Therefore, transcutaneous posterior tibial nerve stimulation is a non-invasive, well-tolerated and effective treatment in the short term for patients with urinary incontinence of refractory urgency. It should be offered early in the course of treatment, even before botulinum toxin. We have found that using an appropriate pacing protocol is essential to achieve an optimal nerve activation without inserting needle electrodes and obtaining good results. However, further studies should be conducted to understand the actual mechanism of action of T-PTNS and to identify the best stimulation parameters. The duration of clinical improvement and optimal long-term management protocols should also be evaluated, as well as the possibility of repeating treatment or applying it chronically given the absence of adverse effects.<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">29</span></a> Finally, more data on the efficacy of T-PTNS are needed in patients with neurogenic overactive bladder, although recent preliminary data seem to confirm the role of posterior tibial stimulation in this condition as well.<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">11,31,32</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conflict of interest</span><p id="par0100" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflict of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres886516" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec872667" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres886515" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec872668" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Materials and methods" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conflict of interest" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2016-12-08" "fechaAceptado" => "2017-01-24" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec872667" "palabras" => array:5 [ 0 => "Overactive bladder" 1 => "Urge incontinence" 2 => "Transcutaneous stimulation" 3 => "Tibial nerve" 4 => "Peripheral neuromodulation" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec872668" "palabras" => array:5 [ 0 => "Vejiga hiperactiva" 1 => "Incontinencia urinaria por urgencia" 2 => "Estimulación transcutánea" 3 => "Nervio tibial" 4 => "Neuromodulación periférica" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To assess the efficacy of treatment with transcutaneous posterior tibial nerve stimulation (TPTNS) in patients with urge urinary incontinence, of neurogenic or nonneurogenic origin, refractory to first-line therapeutic options.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Material and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">We included 65 patients with urge urinary incontinence refractory to medical treatment. A case history review, a urodynamic study and a somatosensory evoked potentials (SEP) study were conducted before the TPTNS, studying the functional urological condition by means of a voiding diary. The treatment consisted of 10 weekly sessions of TPTNS lasting 30<span class="elsevierStyleHsp" style=""></span>min.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Some 57.7% of the patients showed abnormal tibial SEPs, and 42% showed abnormal pudendal SEPs. A statistically significant symptomatic improvement was observed in all clinical parameters after treatment with TPTNS, and 66% of the patients showed an overall improvement, regardless of sex, the presence of underlying neurological disorders, detrusor hyperactivity in the urodynamic study or SEP disorders. There were no adverse effects during the treatment.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">TPTNS is an effective and well tolerated treatment in patients with urge incontinence refractory to first-line therapies and should be offered early in the treatment strategy. New studies are needed to identify the optimal parameters of stimulation, the most effective treatment protocols and long-term efficacy, as well as its applicability to patients with a neurogenic substrate.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Evaluar la eficacia del tratamiento con la estimulación transcutánea del nervio tibial posterior (T-PTNS) en pacientes con incontinencia urinaria de urgencia, de origen neurógenico o no neurógenico, refractaria a las opciones terapéuticas de primera línea.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material y métodos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Se incluyeron 65 pacientes con incontinencia urinaria de urgencia refractaria a tratamiento médico. Antes de T-PTNS se realizó anamnesis, estudio urodinámico y potenciales evocados somatosensoriales (PESS), estudiando el estado funcional urólogico mediante un diario miccional. El tratamiento consistió en 10 sesiones semanales de T-PTNS de 30 minutos de duración.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Un 57,7% de los pacientes presentaban PESS tibiales anormales y en un 42% PESS pudendos anormales. Se objetivó una mejoría sintomática estadísticamente significativa en todos los parámetros clínicos tras el tratamiento con T-PTNS, y en el 66% se evidenció una mejora global, independientemente del género, presencia de alteraciones neurológicas de base, hiperactividad detrusoriana en el estudio urodinámico o trastornos en los PESS. No se produjeron efectos adversos durante el tratamiento.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">T-PTNS es un tratamiento efectivo y bien tolerado en pacientes con incontinencia de urgencia refractaria a terapias de primera línea, y debería ser ofrecida precozmente en la estrategia de tratamiento. Son necesarios nuevos estudios para identificar los parámetros óptimos de estimulación, los protocolos de tratamiento más efectivos y la eficacia a largo plazo, así como su aplicabilidad a pacientes con un sustrato neurogénico.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Valles-Antuña C, Pérez-Haro ML, González<span class="elsevierStyleItalic">-</span>Ruiz de León C, Quintás-Blanco A, Tamargo-Diaz EM, García-Rodríguez J, et al. Estimulación transcutánea del nervio tibial posterior en el tratamiento de la incontinencia urinaria de urgencia refractaria, de origen idiopático y neurógenico. Actas Urol Esp. 2017;41:465–470.</p>" ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 965 "Ancho" => 900 "Tamanyo" => 127692 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Placement of the electrodes for transcutaneous stimulation of the posterior tibial nerve. The black (proximal) electrode corresponds to the active, the red one to the reference, and the green one to the earth wire (safety).</p>" ] ] 1 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">In 26 of the 65 treated patients there was a neurological disease causing bladder overactivity, mainly of the central nervous system (CNS) (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>21): multiple sclerosis, infections (3), tumors (3), vascular alterations (2), Parkinson's disease (1) and multisystemic atrophy (1). Only 5 patients had peripheral nerve disease.</p><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">CNS, central nervous system; PNS, peripheral nervous system.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Cause \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">N</span> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Type \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Idiopathic \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">39 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Non neurogenic \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Multiple sclerosis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">CNS disease \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Tumors of the CNS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Infection of the CNS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Vascular disease of the CNS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Myelopathy (other) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Parkinson disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Myasthenia gravis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Systemic multiple atrophy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Polyneuropathy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Radiculopathy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">PNS disease \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1497973.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Distribution of the series.</p>" ] ] 2 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">R</span>, interquartile range; SD, standard deviation.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Before T-PTNS</th><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">After 9 sessions of T-PTNS</th><th class="td" title="table-head " align="left" valign="top" scope="col"><span class="elsevierStyleItalic">p</span> \t\t\t\t\t\t\n \t\t\t\t</th></tr><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Mean (SD) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Median (<span class="elsevierStyleItalic">R</span>) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Mean (SD) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Median (<span class="elsevierStyleItalic">R</span>) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Daytime voiding frequency \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8.24 (SD: 6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7 (3.7–21) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7.48 (SD: 3.64) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6.50 (<span class="elsevierStyleItalic">R</span>: 2.8–22.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><0.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Nighttime voiding frequency \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.5 (SD: 2.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.85 (0–16.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.03 (SD: 2.16) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.1 (<span class="elsevierStyleItalic">R</span>: 0–13.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><0.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Urgency episodes per day \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.25 (SD: 3.26) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (<span class="elsevierStyleItalic">R</span>: 0–14.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.34 (SD: 2.57) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.1 (<span class="elsevierStyleItalic">R</span>: 0–12.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><0.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Compresses/day \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.78 (SD: 2.05) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (<span class="elsevierStyleItalic">R</span>: 0–7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (SD: 1.82) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (<span class="elsevierStyleItalic">R</span>: 0–6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.0029 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1497974.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">T-PTN results in relation to urinary symptoms (diurnal and nocturnal voiding frequency, daily urgency episodes, and daily compresses used).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:32 [ 0 => array:3 [ "identificador" => "bib0165" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Global prevalence and economic burden of urgency urinary incontinence: a systematic review" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "I. 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