Percutaneous Tibial Nerve Stimulation with Modified Electrical

Stimulator as Therapy for Overactive Bladder Syndrome:

A Serial Case Report

Ricky Gustian Halim

, Steven Setiono

Department of Physical Medicine and Rehabilitation, Dr Cipto Mangunkusumo Hospital,

University of Indonesia, Jakarta, Indonesia

Neuromuscular Division, Department of Physical Medicine and Rehabilitation, Dr Cipto Mangunkusumo Hospital

University of Indonesia, Jakarta, Indonesia

Keywords: Electrical Stimulation, Overactive Bladder, Percutaneous Tibial Nerve Stimulation

Abstract: Overactive Bladder Syndrome (OAB) is a syndrome of increased urinary frequency and nocturia with or

without incontinence in the absence of obvious pathology. Percutaneous Tibial Nerve Stimulation (PTNS) is

one of the neuromodulations used to treat OAB. A modified electrical stimulator was used for PTNS with

the same parameters as Urgent®PC. This study aims to determine whether PTNS with a modified electrical

stimulator will give improvement in OAB and if there are any complications. In this case series, six patients

(three males and three females) diagnosed with OAB were treated with PTNS using a modified electrical

stimulator device (Everyway EV-807P NMES). Electrical stimulations were applied once a week for 12

weeks and each treatment was done for 30 minutes. Reduced urinary frequency is determined as

improvement and assessed at 6th and 12th weeks. Four patients reported improvement. No complications

have been reported. In this case series, PTNS with a modified electrical stimulator may reduce urinary

frequency and maybe a safe option to treat patients with symptoms from OAB. Need further research to

know the definitive result.

1 INTRODUCTION

Overactive Bladder Syndrome (OAB) is a syndrome

of increased urinary frequency and nocturia with or

without incontinence in the absence of obvious

pathology (Wibisono and Rahardjo, 2016; Wall and

Heesakkers, 2017). It is estimated that there are

around 455 million people (11% of the world

population ranging from 1,5% to 36,4%) having

experienced OAB symptoms during their life and

resulting in a substantial economic, psychological

burden and negatively impacted their quality of life

(Wibisono and Rahardjo, 2016; Wall and

Heesakkers, 2017). A study (Sumardi et al., 2014)

reported that the prevalence in Indonesia for wet

OAB is 4.1% and dry OAB is 1.6%.

The treatments of OAB consist of four classes:

conservative treatment, pharmacotherapy, surgical

therapy, and additional therapy for intractable OAB.

The first line treatments are conservative treatment

and pharmacotherapy and for second line treatment

available are surgical therapy, electrical stimulation

(sacral nerve stimulation, percutaneous tibial nerve

stimulation), and botulinum toxin injection

(Wibisono and Rahardjo, 2016).

Percutaneous tibial nerve stimulation (PTNS) is

one of the neuromodulations therapies for OAB that

is minimally invasive and could stimulate posterior

tibial nerve and deliver electrical stimulation to

sacral nerve plexus (Wibisono and Rahardjo, 2016;

Wall and Heesakkers, 2017; Tutolo et al., 2018).

The regulation of the bladder is controlled by sacral

plexus originating from L2-S4. The nerves converge

toward and descend as the sciatic nerve and one of

its distal branches is the posterior tibial nerve (Wall

and Heesakkers, 2017).

PTNS in various studies is done by using

Urgent®PC (Uroplasty, Minnetonka, MN, USA) as

the stimulator (Gaziev et al., 2013; Peters et al.,

2013; Wall and Heesakkers, 2017; Tudor et al.,

2018). In this case series, due to the unavailability of

Urgent®PC, modified electrical stimulator was used

for PTNS with the same parameters as Urgent®PC.

Halim, R. and Setiono, S.

Percutaneous Tibial Nerve Stimulation with Modiﬁed Electrical Stimulator as Therapy for Overactive Bladder Syndrome: A Serial Case Report.

DOI: 10.5220/0009087601770180

In Proceedings of the 11th National Congress and the 18th Annual Scientiﬁc Meeting of Indonesian Physical Medicine and Rehabilitation Association (KONAS XI and PIT XVIII PERDOSRI

2019), pages 177-180

ISBN: 978-989-758-409-1

177

This study aims to determine whether PTNS with a

modified electrical stimulator will give improvement

in OAB and if there are any major complications.

2 CASE DESCRIPTION

Six patients (three males and three females) with

OAB that have been treated with Vesicare® from

Urology Department were consulted to Medical

Rehabilitation Department in RSUPN Dr. Cipto

Mangunkusumo. All of the patients complained

about increased urinary frequency in 24 hours. The

urinary frequency ranged from 17 – 30 times per 24

hours. All of the patients were treated with PTNS as

management of OAB. PTNS was done by using a

modified electrical stimulation device (Everyway

EV-807P NMES) with low voltage (9V) and the

setting for pulse width of 200 microseconds and

frequency of 20 Hz (Figure 1).

Figure 1: A modified electrical stimulation device

(Everyway EV-807P NMES).

For the procedure (Figure 2), patients were asked

to sit comfortably in a chair with the leg that would

be treated was elevated. A small and slim needle

(acupuncture needle 0.25x25 mm) as stimulator

electrode (needle electrode) was inserted

percutaneously to the posterior edge of the tibia and

about 5 cm cephalad from the medial malleolus

(about four fingers above medial malleolus). The

other electrode (pad electrode) as grounding was

placed on the medial surface of the calcaneus (same

side with the stimulator electrode). The electric

current was increased until the patient feels a

radiation tingling sensation of the foot sole or

flexion of the great toe. Then the current was set at

the highest level that can be tolerated by the patient

and continued for 30 minutes. Each treatment was

done for 30 minutes, and the electrical stimulations

were applied once a week for 12 weeks.

Figure 2: Electrode placement

Urinary frequency per day was reported as a

measurement of improvement of OAB and assessed

at 6

and 12

weeks (Table 1). Improvement of

OAB was defined as patients who had at least a 25%

reduction in urinary frequency. In 6

weeks, three

patients reported improvement and three patients

reported no improvement in urinary frequency. In

weeks, four patients reported improvement and

two patients reported no improvement in urinary

frequency. No major complications have been

reported during treatment and all of the patients

complied for PTNS.

Table 1: Patients profile and results after PTNS.

Patient

Age

(years)

Gender

Frequency

(times per day)

Female

Male

3 DISCUSSION

PTNS is a neuromodulation treatment that stimulates

lumbosacral nerves (L4- S4) which control bladder

detrusor and perineal floor via the posterior tibial

nerve located near the ankle. The mechanism of

neuromodulation is still unclear, but it is believed

that stimulation of the lumbosacral nerves via the

posterior tibial nerve located will altered the afferent

KONAS XI and PIT XVIII PERDOSRI 2019 - The 11th National Congress and The 18th Annual Scientiﬁc Meeting of Indonesian Physical

Medicine and Rehabilitation Association

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and efferent pathways between the brain, brain stem,

and pelvic organs and eventually modulate the

voiding reflex and facilitate storage (Wall and

Heesakkers, 2017).

Neuromodulation utilizes electrical stimulation

to target specific nerves that control bladder function

(Burton, Sajja and Latthe, 2012). In various studies,

PTNS was done by using Urgent®PC (Uroplasty,

Minnetonka, MN, USA). In this study, electrical

stimulation was done by using a modified device

with the same parameters with Urgent®PC as a

stimulator due to unavailability of Urgent®PC. We

modified an electrical stimulation device (Everyway

EV-807P NMES) as a substitute for Urgent®PC.

The modifications were made for the needle

electrode and power source. For the needle

electrode, a modification was made by changing the

pad electrode with a crocodile clip. As for the power

source, modification was made by changing the

power source from batteries to direct electricity

through an adapter. The voltage of the adapter was

set at 9V as described in a study (Burton, Sajja and

Latthe, 2012). The setting for pulse width and

frequency were set in 200 microseconds, 20 Hz as

the standard settings of the device (Peters et al.,

2012).

In this study, the protocol of treatment was done

following standard protocol as mention in many

studies (Burton, Sajja and Latthe, 2012; Peters et al.,

2012; Gaziev et al., 2013; Wall and Heesakkers,

2017). Each treatment was done for 30 minutes, and

the electrical stimulations were applied once a week

for 12 weeks. The placement of the needle electrode

at the posterior edge of the tibia and superior to

medial malleolus and grounding electrode at the

medial surface of the calcaneus.

In some systematic reviews the range of

successful treatment was 37-82% (Burton, Sajja and

Latthe, 2012), 54.5-79.5% (Gaziev et al., 2013),

37.3-81.8% (Wibisono and Rahardjo, 2015). The

success rate was varied depending on the criteria

determined by each author as mentioned in a

systematic review (Burton, Sajja and Latthe, 2012).

The criteria

were 50% reduction in symptoms (frequency or

urgency incontinence episodes); 25% reduction in

daytime and/or night time frequency; < 8 voids/24

hr, 0–1 urgency episode in 24 hr, no urgency

incontinence; < 8 voids, < 2 nocturia episodes and

0–1 g on pad test. In this case series, the success

treatment criteria was defined as patients who had at

least a 25% reduction in daytime and/or nighttime

frequency as in a study by Govier et al., 2001. From

the study, 71% of patients were classified as

successfully treated after 12 weeks. In this case

series, four patients (66.6%) from six patients were

classified as successfully treated.

From the studies reported in a meta-analysis

(Wibisono and Rahardjo, 2015), PTNS had no

serious adverse event. The rare complications found

in PTNS treatment were ankle bruising, discomfort/

pain at the needle site, bleeding at the needle site,

tingling in leg, generalized swelling, worsening

incontinence, headache, hematuria, inability to

tolerate stimulation, intermittent foot/toe pain and

foot cramp. In this case series, there were no major

complications had been reported.

4 CONCLUSIONS

PTNS with a modified electrical stimulator may

reduce urinary frequency and maybe a safe option to

treat patients with symptoms from OAB. Need

further research to know the definitive result.

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Medicine and Rehabilitation Association

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