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Percutaneous Tibial Nerve Stimulation for Treatment of Refractory Overactive Bladder Syndrome
a placebo effect cannot be ruled out. Therefore, a placebo-controlled more difficult to discuss for both patients and care-givers than urinary
trial or a comparison with a sham arm still needs to be performed. It dysfunction. As the first steps are taken in exploring the value of SNS
should be noted that to our knowledge no neuromodulation in this field,
43
it can be anticipated that research on PTNS for this
techniques have been properly tested against placebo. indication will also be performed.
44
Which Patients Benefit from Percutaneous What Is the Best Stimulation Protocol?
Tibial Nerve Stimulation? Almost all research performed on PTNS used 10–12 weekly sessions of
Since PTNS needs approximately six to eight sessions before results are 30 minutes. Stimulation parameters were fixed and only one needle was
obtained, predictive factors for successful outcome are urgently inserted per session. Other treatment schemes and/or stimulation
needed. Studies in neuromodulation show that the best candidates are parameters also could lead to improvement. The same goes for bilateral
psychologically sound patients with mild to moderate DO. More instead of unilateral therapy. An accelerated scheme of three to four
research should be carried out to identify the criteria that increase times a week seems not to significantly influence treatment outcome,
success. As soon as an implant for chronic TNS is available, efforts although there are some conflicting reports regarding its effects on
should be undertaken to refine the pre-implant testing phase in order maintenance therapy afterwards.
22,36
However, an accelerated scheme
to decrease the number of unnecessarily treated patients. Also, achieved clinical results earlier.
45
optimising the success of PTNS treatment will lead to the exploration
of other indication groups, such as children, neurogenic patients and It is widely agreed that pulse intensity in neuromodulation should be
patients with faecal incontinence. set at a tolerable level. However, frequency has been varied in the
different neuromodulation techniques from 5 to 20Hz, but even
Neuromodulation techniques seem less suitable for children because frequencies up to 150Hz are reported. It is known that pulse
of their invasive nature and the necessity to apply current in the anal frequencies below 20Hz may produce interesting results, although
and/or genital area. Although PTNS is not ‘non-invasive’, its focus on 5–6Hz frequencies are unpleasant.
46
The same goes for changes in
the ankle might be less threatening to children. Promising results pulse duration in PTNS set at 0.2msec. The effect of stimulating
reported in the first two studies in 31 and 23 children, respectively,
38,39
both legs at the same time is also interesting. In SNS there are
warrant further evaluation. indications that bilateral stimulation increases the chance of a positive
patient response.
47–49
The second challenging patient group consists of neurological
patients. Neuromodulation treatment in selected cases, especially in Conclusion
multiple sclerosis, may be of benefit as well. Up until now, experience PTNS is known as the poor man’s neuromodulation technique. It
in this field is limited and contradictory,
39-42
but results are brings one type of neuromodulation within reach of every clinician.
encouraging and the complaints are so distressing that more effort Increasing studies have been published that show clinical and
is justified. urodynamic effects. The real value, however, still has to be determined
and other PTNS modalities have to be explored. With solid data this
Finally, an area beyond the interest of most urologists but in many technique can be extended in clinical practice for various disorders.
ways comparable to LUTD is that of faecal incontinence. Faecal The future will tell us whether PTNS results are so robust that it can
incontinence has a high impact on the QoL of patients but seems even stand the test of time. ■
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