Khavari R, Tran K, Helekar SA et al: Noninvasive, individualized cortical modulation using transcranial rotating permanent magnet stimulator for voiding dysfunction in women with multiple sclerosis: a pilot trial. J Urol 2021; 207: 183. https://doi.org/10.1097/JU.0000000000002297.

Figure. Treatment procedure. Lt, left. MRI, magnetic resonance imaging. ROI, region of interest. Rt, right. SMA, supplementary motor area. UDS, urodynamic study.

Study Need and Importance: Voiding dysfunction (VD; difficulty emptying the bladder) is morbid, costly and leads to urinary tract infections, stones and renal failure. Currently, the only effective therapy for VD is catheterization, which is a burden, especially in neuropathic patients, such as women with multiple sclerosis (MS), who commonly exhibit lower extremity spasms and compromised hand dexterity. The cost and morbid side effects associated with catheterization encouraged us to investigate potential therapeutic targets beyond the bladder, such as the brain. We proposed to utilize our unique neuroimaging/urodynamic platform to identify brain regions involved in voiding initiation in women with MS with VD and then to perform targeted and multifocal cortical neuromodulation of these areas to improve bladder emptying (see figure). Transcranial rotating magnetic stimulation is an investigational and portable device that can noninvasively and simultaneously modulate multiple cortical regions.

What We Found: In 10 MS women with VD, individualized transcranial rotating magnetic stimulation was able to modulate (increase or decrease) activation patterns in brain regions involved in initiation of voiding, as well as other cortical and subcortical brain regions involved during both storage and voiding phases of the bladder. More importantly, these cortical changes were reflected in improving bladder emptying by significantly 1) decreasing uroflow parameters: post-void residual and % post-void residual/bladder capacity; and 2) improving validated questionnaire scores: Neurogenic Bladder Symptom Score and question 3 of the American Urological Association Symptom Score (continuous stream).

Limitations: Although these results are promising, important limitations exist. Our study was designed as a pilot feasibility trial and included a small and homogeneous group of women with MS without a control arm.

Interpretation for Patient Care: Nevertheless, the results of this pilot study could lay the foundation for larger randomized trials to individualize neuromodulation of cortical regions involved in voiding, not only in MS but in other etiologies of VD such as patients with Fowler’s syndrome, stroke or underactive bladder.