Electrical Stimulation of the Transcutaneous Posterior Tibial Nerve

for the Treatment of Patients with Detrusor Overactivity

Due to Neurogenic Hiperactive Bladder in Multiple Sclerosis

A Case Study

Fabiana S. B. Perez

, Luciana R. Tenório Peixoto

, Fabiano Soares

Cristiano Jacques Miosso

and Adson F. da Rocha

School of Medicine, University of Brasilía, Brasília, DF, Brazil

University of Brasília at Gama, Gama, DF, Brazil

Keywords: Electrical Stimulation, Multiple Sclerosis, Neurogenic Bladder Incontinence and Posterior Tibial Nerve.

Abstract: This case study evaluates the therapeutic use of Transcutaneous Electrical Nerve Stimulation (TENS) of the

posterior tibial nerve for treating one patient with multiple sclerosis (MS) showing signs of urinary

incontinence (UI) due to detrusor overactivity (DO). Patient: MS with UI and sensory loss. Method: Using

the current therapy twice a week for 20 minutes in 10 sessions and monitoring electrodes during electrical

stimulation. Results: We observed an improvement in urge incontinence with reduced trips to the bathroom

during the day and night. Both the post voiding sense of desire and pain during urination disappeared.

Conclusions: This study shows an indication that the use of TENS in the current technique of posterior tibial

nerve can reduce the uninhibited detrusor contractions and improve the quality of life of patients with MS

due to a reduction of urinary incontinence and also reduce the number of times that the patient's urinates,

thus providing better quality of sleep, humor, personal relationship, less embarrassment and reduction of

stress. In this way, this study justifies a wide investigation with multiple subjects.

1 INTRODUCTION

Multiple sclerosis (MS) is a neurological disease of

high incidence in young adults with a picture of

multifocal demyelination in the central nervous

system (Coelho, 2009; Poser , 1986; Misulis, 2008).

The urgency or urinary incontinence (UI) may occur

as the initial manifestation in most patients with MS

(Stephen, 1995).

Involuntary loss of urine is a problem of social

order and hygiene, causing embarrassment and

changes in behavior such as social isolation, low

self-esteem and psychosocial disorders (Oliveira,

2010). The most common etiology of urinary

incontinence is neurogenic (Monteiro, 2009).

The four handles or neurological pathways in the

control of urination, and which are related to each

other, are: the core trunk detrusor cerebral cortex

(loop I), the core detrusor muscle spinal / sacral

brainstem (loop II)-sacral urethral sphincter of the

bladder (loop III), and the sacral-brain (loop IV).

Pathways I and IV are responsible for voluntary

control of urination. Pathways II and III, on the other

hand, regulate the contractions of the detrusor

bladder emptying to promote and coordinate efforts

between the detrusor and urethra (Stephenson and

O’Connor, 2004).

The neurogenic bladder dysfunction is defined as

a neurological disease produced by nerve damage

that interferes with the mechanisms of voluntary and

involuntary urination, thus causing changes in

normal bladder function

. The neurogenic bladder

corresponds to the overactive and/or underactivity of

the detrusor (Azevedo et al, 1990).

The

underactivebladderretentionoroverflowis

characterized by

 urinary loss that occurs when

intravesical pressure exceeds urethral pressure. This

is associated with bladder distention, but in the

absence of detrusor activity. This overflow happens

when one reaches the limits of distensibility or

compliance of the bladder (Miltrano, 2009).

According to the International Continence

Society, the overactive bladder is defined as a

neurogenic injury due to the presence of involuntary

154

S. B. Perez F., R. Tenório Peixoto L., Soares F., Jacques Miosso C. and F. da Rocha A..

Electrical Stimulation of the Transcutaneous Posterior Tibial Nerve for the Treatment of Patients with Detrusor Overactivity Due to Neurogenic Hiperactive

Bladder in Multiple Sclerosis - A Case Study.

DOI: 10.5220/0004806101540158

In Proceedings of the International Conference on Biomedical Electronics and Devices (BIODEVICES-2014), pages 154-158

ISBN: 978-989-758-013-0

 2014 SCITEPRESS (Science and Technology Publications, Lda.)

detrusor contractions during the filling phase

(Coelho, 2009). This is characterized by urinary

incontinence, urinary frequency, nocturia and

urgency (Fischer-Sgrott et al, 2009).

The existent techniques of treatment for UI are

electrostimulation applications directed to the

perineum muscle, using either internal anal

electrodes for men or surface electrodes in the

region. These two techniques are embarrassing,

invasive (in the first case) and may cause discomfort

and burns if the patient has abnormal sensibility

(Marques, 2008).

Treatments with transcutaneous electrical

stimulation in the posterior tibial nerve aim at

reducing UI and assume that the path of the nerve

there are neuronais projections of the bladder

(Fischer-Sgrott et al, 2009).

The TENS current is used for the treatment of

urinary incontinence by bladder hyperactive (BH).

The electrodes are placed bilaterally in the medial

region of the legs, causing motor and sensory

stimulation as the current is applied. During each

session, the patient’s neurological physiotherapist

observes the stimulation caused by the motor

current, and the sensory way is not changed to

modulate the current flow. This technique promotes

the reduction of involuntary detrusor contractions

(Marques, 2008). Regarding the TENS current for

the treatment of BH, some researchers propose a

sequence of pulses with a frequency of around 20 Hz

and with a duration of around 200 miliseconds per

pulse (Amarenco, 2003).

The therapies using electric currents can be used

in neurological patients with abnormal sensitivity,

because applying electrical stimulation displays

rhythmic flexion of the hallux, thus indicating the

correct placement of electrodes and confirming this

to be intact innervation (Maciel and Souto, 2009).

However, in individuals with Babinski's reflex, it is

difficult to dispense the current therapeutic

modulation due to incorrect motor response they

have, so that it becomes impossible to control the

intensity offered by the device and electro-motor

response.

In the case of hyposensitivity, the dose should be

applied until it causes rhythmic inflections of the big

toe, and it should then be reduced until the motor

action disappears. The provided dose agrees with

several studies arguing that the ideal intensity must

be maintained according to the threshold of each

patient and below the motor threshold (Fischer-

Sgrott et al, 2008; Maciel and Souto, 2009;

Amarenco et al, 2003; Kabay et al, 2009).

2 CLINICAL CASE

A 36 year-old black male, married and with one son.

At the age of 28, after suffering a crisis caused by

the disease, the patient was diagnosed with MS.

After a few years, another MS crisis occurred, with

the same characteristics aforementioned, and the

patient again recovered later. The patient reported

having suffered from UI starting 6 years after the

MS was found, and that the UI was diagnosed as

caused by neurogenic overactive bladder, as

confirmed by urodynamic examination.

During the evaluation, the patient was lethargic,

with initiative and responsive. In neurological

evaluation, we noted sensory deficit and the

presence of cutaneous reflex - planting. In the

evaluation of urogynecologic history, we noted that

the main complaint consisted of dysuria, urinary

frequency and incontinence urge. We found that the

frequency of urination during the day corresponded

to 15 trips to the bathroom to urinate and during the

night corresponded to 9 trips to the bathroom, which

confirmed the picture of urinary urgency and

nocturia. The patient reported pain and post-voiding

desire during the act of micturition. He also reported

the presence of active sexual activity with urination,

as well as hypertension. He denied making use of

liners even with urinary incontinence in clothes.

3 METHOD

On the first evaluation day, we applied the

physiotherapy assessment protocol forms, which the

patient completed in the Urogynecology laboratory

at Unifesp. We instructed the patient to complete a

voiding diary for three days after treatment.

During the neurological assessment, a physical

examination showed no sensory deficit and bilateral

Babinski's reflex. Given that no pathological reflex

existed, we positioned the electrodes in the path of

the posterior tibial nerve, to detect whether

innervation was intact, by using electrical

stimulation (we used the TENS NEURODYN/FES

portable device, by Ibramed Ltda). This stimulation

was based on a sequence of 200-milisecond puses,

with a frequency of 20 Hz, following the

recommendation by (Amarenco, 2003). Since the

patient had reported hypertension before the

treatment, his blood pressure (BP) was monitored in

all the sessions.

The treatment protocol consisted of 10 sessions,

twice a week and lasting 20 minutes each. We

ElectricalStimulationoftheTranscutaneousPosteriorTibialNervefortheTreatmentofPatientswithDetrusor

OveractivityDuetoNeurogenicHiperactiveBladderinMultipleSclerosis-ACaseStudy

155

applied the TENS current through two channels,

using four electrodes positioned transcutaneously

and bilaterally in the lower limb (2 electrodes per

channel). For each channel, one electrode was fixed

to the posterior medial malleolus and the other

10 cm above. The intensity parameter due to

hyposensitivity was measured through the signal

engine rhythmic inflections of hallux. A maximum

intensity of 30 mA was applied, for safety reasons.

Figure 1: Positioning of the 4 eletrodes, two for each

channel, used to apply the electric currents during the

TENS sessions.

4 RESULTS AND DISCUSSION

This paper presents results of a case study monitored

by descriptive assessments from the Unifesp

Physiotherapeutic Protocol in Urogynecology and

the voiding diary for three days. The patient was

submitted to physiotherapeutic treatment with

transcutaneous electrical stimulation in order to

attenuate urological clinical complaints. This

justifies the choice of a treatment by elective

electrostimulation – separated from other techniques

such as kinesiotherapy. Both evaluation procedures

were applied i) before treatment, ii) after 20 TENS

sessions, iii) within a year after being treated with

TENS. It should be noted that the patient was still

followed and evaluated after discharge from

physiotherapeutic urological attendance and the

same clinical signs obtained after 20 TENS sessions

were preserved.

This case study of urinary incontinence treatment

in a MS patient was made possible because the same

therapist followed the patient throughout the study,

even though the latter was also attended for

treatment of other neurological symptoms such as

unsteadiness and difficulties with static and dynamic

coordination, aggravated during crises. MS patients

commonly face periods of illness aggravation and

remission. Nevertheless, clinical urological results

obtained in this case study remained constant even

after a year.



According to Kabay et al (2009), when applied

to people suffering from multiple sclerosis, the

technique noticeably decreased nocturia in 75% of

patients. Marques (2008) reports decrease in

nocturia with 38% of symptoms relief. Another

study found improvement in nighttime urination in

21% of cases (Govier et al, 2001). Table 1 shows

that after 10 sessions of electrical stimulation of the

posterior tibial nerve, there was decrease in the signs

of urinating discomfort, as well as reduction in the

number of urinary frequency during the day,

nocturia, and urgency incontinence episodes. We

can justify improvement of urinary urgency

conditions through a study in which urodynamic

evaluation with electrical stimulation of the posterior

tibial nerve revealed maximum bladder capacity can

increase together with a decrease of involuntary

detrusor contractions during standard cystometry

(Amarenco, 2003).

Table 1: Urologic evaluation of signs frequency before

treatment (f

before

), after 10 sessions (f

) and after one year

of treatment (f

1year

) with electrical stimulation sessions.

Main

complaint

before

10 sessions

20sessions

F1year

Nocturia

9 5 0 0

Void desire

during the

day

15 3 a 4 normal normal

Sensation

act voing

pain and

desire

after

voing

burning confortable Confortable

Urge

incontinence

2.7 1.3 normal normal

Cause of

urinary loss

urge

incon-

tinence

urge

incontinence

normal normal

after 20 sessions

In general, urinary incontinence treatment was

considered effective given the observation that

urinary loss episodes were reduced by 50%. With

regard to this parameter, involuntary loss of urine

onto clothes was reported 5 times by the patient

before treatment due urge incontinence and 2 times

after 10 electrical stimulation sessions. This

reduction may be explained in terms of possible

neuromodulation provoked by the TENS current.

BIODEVICES2014-InternationalConferenceonBiomedicalElectronicsandDevices

156

This research found a limitation in the loss of

patient sensibility caused by MS.

According to Tilbery (2006), it is common for

patients with MS to present paraparesis of varying

intensity, especially in the lower limbs. Therefore,

the difficulty of using electrotherapy with these

patients consists in adjusting the intensities of the

current. We propose to perform the sensitivity test

before applying the therapeutic current. During

electrical stimulation it is important to carefully

observe the threshold of individuals with

hypersensibility. For that reason, the current

intensity should be slowly graded until reaching an

individualized parameter below the stimulation

threshold of motor innervation (Kabay et al, 2009;

Amarenco, 2003; Fischer-Sgrott et al, 2009; Maciel

and Souto, 2009).

5 CONCLUSIONS

The transcutaneous electrical stimulation in the

posterior tibial nerve can be considered as an

alternative in the treatment of urinary incontinence

in detrusor hyperactivity. Our results suggest that the

technique may be effective in reducing the

uninhibited detrusor contractions after 10 sessions of

electrostimulation.

This technique is also relatively inexpensive,

non-invasive, non-embarrassing, comfortable,

painless, effective, with targeted action on the

detrusor muscle, easy to apply and free of side

effects of medications. Also, we believe that it can

have high acceptance and adherence by the patients,

since it does not result in great discomfort and each

session takes 20 minutes.

We emphasize that, in this study, the technique

resulted in a reduction in daytime and nighttime

urinary frequency and in the number of episodes of

urge incontinence. It can then have an impact in

reducing stress and embarrassment and the number

of urinary tract infections, as well as improving

sleep quality and mood and thus providing a better

quality of life for individuals with MS. It is then a

good alternative in the treatment of lower urinary

tract dysfunction, as suggested by the patient in this

study.

ACKNOWLEDGEMENTS

We leave to express our sincere thanks to Doctor

Denise Sistorelli Diniz, a neurologist at the Hospital

das Clínicas, Federal University of Goiás, for

supporting our research. The authors thank the

Alfredo Nasser Scholl (Unifan).

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