Elsevier

Journal of Pediatric Urology

Volume 13, Issue 3, June 2017, Pages 263.e1-263.e6
Journal of Pediatric Urology

Parasacral transcutaneous electrical neural stimulation (PTENS) once a week for the treatment of overactive bladder in children: A randomized controlled trial

https://doi.org/10.1016/j.jpurol.2016.11.019Get rights and content

Summary

Introduction

Overactive bladder (OAB) is the most prevalent voiding disorder in childhood, and its main manifestation is urinary urgency. In general, urotherapy and anticholinergics are the first choices of treatment. Parasacral Transcutaneous Electrical Neural Stimulation (PTENS) was introduced as an alternative for the treatment of detrusor overactivity in children, but treatment protocols described to date require several sessions per week or long-lasting sessions, making it difficult for the child to adhere to the treatment. Thus, this study aims to evaluate the effectiveness of PTENS in single weekly sessions in the treatment of OAB in children.

Study design

This prospective, randomized controlled trial included 16 children with OAB. Children were divided into two groups: CG (urotherapy and electrical stimulation placebo) and EG (urotherapy and PTENS). For both groups, therapy was delivered in 20 weekly sessions, of duration 20 min each. Placebo electrical stimulation was done in the scapular area. The children were evaluated prior to treatment (T1), at the end of the 20 sessions (T2), and 60 days after the completion of treatment (T3), with a 3-day voiding diary, visual analogue scale (VAS), Rome III diagnostic criteria, and the Bristol Scale.

Results

The groups were similar in age, gender, and ethnicity. In the initial assessment, all children, in both groups, had urgency and incontinence, 50% in each group had constipation, and enuresis was present in seven children (87.5%) in the EG and six (75%) in the CG. No differences were found between the groups regarding the volumetric measurements made in the voiding diary, urinary frequency and constipation evaluated by the Rome III criteria and the Bristol Scale. Sixty days after treatment, a significant improvement was found in the EG group (p = 0.03) regarding urgency (Table), as well as an increase in dry nights in those presenting with enuresis (p = 0.03). No difference was noted regarding urinary incontinence (Table). At the end of 20 sessions and after 60 days of treatment, those responsible for the children in the EG perceived greater improvement in symptoms measured by the VAS (p = 0.05 and 0.04, respectively).

Conclusions

Our preliminary results demonstrate that PTENS performed in single weekly sessions is effective in treating the bladder for symptoms of urinary urgency and enuresis, and in the perception of those responsible for the children. Further studies with larger populations are needed to corroborate these results.

Table. Urgency and urinary incontinence after treatment.

Empty CellEG, n (%)CG, n (%)p
Urgency
T1
 Yes8 (100.00)8 (100.00)1.00
 No0 (0)0 (0)
T2
 Yes3 (42.86)6 (85.71)0.26
 No4 (57.14)1 (14.29)
T3
 Yes2 (28.57)6 (85.71)0.03
 No5 (71.43)1 (14.29)
Urinary incontinence
T1
 Yes8 (100.00)8 (100.00)1.00
 No0 (0)0 (0)
T2
 Yes2 (28.57)5 (71.43)0.28
 No5 (71.43)2 (28.57)
T3
 Yes2 (28.57)5 (71.43)0.28
 No5 (71.43)2 (28.57)

Introduction

Overactive bladder (OAB) is the most prevalent urinary disorder in childhood. Its main clinical feature is the presence of urinary urgency. Symptoms of incontinence, pollakisuria, and nocturia may or may not be present [1], [2]. Griffiths et al. (2005) demonstrated an association between poor bladder control and abnormal activation of the frontal cortex [3]. It is believed that a delay in developing cortical centers involved in controlling the bladder is responsible for causing involuntary detrusor contractions during filling, and these would be recognized as a sudden and irresistible desire to urinate [2], [4].

There is an intimate relationship between constipation and overactive bladder. It is believed that the increased fecal volume may trigger bladder contractions, besides reducing the functional capacity of the bladder [5]. Moreover, children with urinary urgency tend to inhibit this desire via retention maneuvers, which cause the retention of evacuation. Moreover, fecal retention increases bladder pressure, which leads to an increased urgency, recurrent urinary tract infections, and post-void residual urine [6].

Urotherapy is often the first line of treatment for these children. Adequate fluid intake, time voiding, treatment of constipation, orientation regarding posture to urinate, and avoiding retention maneuvers are among the behavioral changes that should be adopted [2], [7], [8]. Besides urotherapy, anticholinergic drugs are often used, but have significant side effects, especially constipation, which can lead to non-compliance or dropout from the treatment [9].

Parasacral Transcutaneous Electrical Neural Stimulation (PTENS) was introduced as an alternative method for treatment of children with detrusor overactivity who did not respond to previous treatments with anticholinergics. Early studies evaluating this method were conducted with daily sessions [10], [11]. Later, other authors evaluated PTENS with three sessions a week and found it to be safe and well tolerated, demonstrating effectiveness in the short- and long-term treatments of children with OAB [12], [13], [14]. However, travel from smaller urban areas to larger centers where the treatment is offered increases costs with transportation and demands, and increases time required for all the treatment sessions, which can reduce adherence to treatment or even prevent it from being carried out.

In an attempt to avoid such complications, the present study aimed at evaluating the feasibility and effectiveness of PTENS performed with single weekly sessions for treatment of OAB in children.

Section snippets

Patients and methods

A controlled prospective randomized study was conducted, after being approved by the research ethics committee of our institution, including children aged 3–18 years of age with a clinical diagnosis of OAB not previously treated for this disease or having gone at least 6 months without any treatment, and whose parents signed the informed consent form. OAB was defined as the presence of urinary urgency with or without incontinence and not in the presence of urinary tract infection. Children with

Results

Sixteen children with clinical diagnosis of OAB were included in the study, with eight of them being randomly allocated to each group. The groups were similar in age, gender, and ethnicity and EBC (Table 1). Socioeconomic issues meant that two children (one from each group) found it difficult to attend the sessions and withdrew from the study.

No differences were found in any of the volumetric measurements assessed by the voiding diary (average voiding volume, average voiding volume per day, and

Discussion

The number of studies using PTENS to treat children with clinical diagnosis of OAB has grown over time, as it is considered to be an effective, non-invasive and easy to apply modality [15]. It is believed that neuromodulation produces a physiological effect, allowing remodeling of synapses through neuroplasticity mechanisms, possibly promoting neural definitive reconditioning [16]. Experimental studies in cats demonstrated that neuroelectrical stimulation of the sacral routes activates, through

Conclusions

Our preliminary results demonstrate that PTENS performed once a week, associated with urotherapy, is effective in treatment of OAB regarding its main clinical symptom (urinary urgency), the subjective perception of those responsible for the resolution of symptoms, and also decreasing the episodes of enuresis.

Funding

None.

Conflict of interest

None.

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