Attention: Restrictions on use of AUA, AUAER, and UCF content in third party applications, including artificial intelligence technologies, such as large language models and generative AI.
You are prohibited from using or uploading content you accessed through this website into external applications, bots, software, or websites, including those using artificial intelligence technologies and infrastructure, including deep learning, machine learning and large language models and generative AI.
Posterior Tibial Nerve Stimulation for Lower Urinary Tract Dysfunction in Children
By: Zoe Gan, MD, University of Pennsylvania Perelman School of Medicine, Philadelphia; Adriana Messina, MSN, CRNP, The Children’s Hospital of Philadelphia, Pennsylvania; Katherine Fischer, MD, The Children’s Hospital of Philadelphia, Pennsylvania; Jason Van Batavia, MD, MSTR, FAAP, The Children’s Hospital of Philadelphia, Pennsylvania | Posted on: 27 Jun 2023
Posterior tibial nerve stimulation (PTNS) is a third-line treatment option for overactive bladder (OAB) in adults after behavioral modifications and pharmacotherapy per the American Urological Association guideline on nonneurogenic OAB. However, it can also be used to treat children, as dysfunctional lower urinary tract symptoms (LUTS) and lower urinary tract dysfunction are prevalent in approximately 20% of otherwise healthy school-age children.1 The United States Food and Drug Administration (FDA) approved sacral neuromodulation for OAB in 1997, followed by PTNS as a peripheral target treatment alternative in 2000. PTNS is not considered off label for use in children since no targeted age was specified at the time of approval. Current FDA-approved devices for office-based PTNS include NURO and Urgent PC. Recently, the FDA approved a novel PTNS device for adults, eCoin, that can be implanted peripherally at the posterior tibial nerve.
The exact mechanism of action of PTNS is unknown, although the practice is likely derived from ancient Chinese acupuncture. The posterior tibial nerve is a mixed peripheral sensory motor nerve that originates at the L4-S3 level of the spinal cord, which overlaps with the origin of parasympathetic nerves of the bladder (L5-S3). Similar to sacral nerve stimulation, tibial nerve simulation is hypothesized to reorganize and regulate spinal reflexes as well as provide afferent signaling to the micturition center that helps restore the balance of excitatory and inhibitory signals affecting bladder function.2 These changes lead to downstream effects such as decreased bladder overactivity.
Office-based PTNS generally involves continuous stimulation with an external device for 30 minutes weekly over a 12-week treatment period in an outpatient setting. Ideally, the treatments do not occur less than 4 days or more than 10 days apart. The intensity of the stimulation varies depending on the needle’s proximity to the tibial nerve. Appropriate placement is indicated by big toe flexion or a patient’s subjective sensation of stimulation in the foot and toes. With traditional PTNS, a 34-gauge needle about 4 cm in length is placed about 3 cm cephalad to the medial malleolus. The transducer wire is clipped to base of the needle at the skin insertion site, and a grounding pad is placed on the arch of the same foot. The patient can lie supine or sit upright in a chair with the therapy foot elevated. A demonstration of needle placement and transducer wire setup with the stimulation device connected to the grounding pad sticker is shown in the Figure. As a less invasive alternative, transcutaneous PTNS may also be performed by placing surface electrodes on tibial nerve innervation sites.
Several prospective and retrospective studies on PTNS in children without a control group have shown promising results. These studies generally include children with a mean age of 9-12 years with persistent LUTS despite 1-2 years of behavioral modifications and pharmacotherapy. PTNS has been shown to improve or resolve a variety of LUTS including frequency and urgency in the majority of treated patients,3 increase bladder capacity,4 increase voided volumes, and decrease post-void residual for at least 50% of patients with dysfunctional voiding and about 30% of patients with OAB.5 Additionally, studies of PTNS in these children have shown normalization of uroflowmetry curve in at least 40% of patients4 and improved quality of life for both children and parents.6 Of note, PTNS appeared to be less effective in patients with neurogenic bladder, with neurogenic bladder patients having no significant changes in symptoms or urodynamic parameters in 1 study3 and having only 14% improvement in LUTS immediately after completing the treatment cycle compared to 78% nonneurogenic patients in another study.5
While there are currently no randomized controlled trials (RCTs) comparing traditional PTNS to sham treatment, RCTs comparing transcutaneous PTNS with sham treatment have conflicting results. A double-blind RCT in children with nonneurogenic OAB showed that both treatment and sham groups had improvement in urodynamic parameters, the sham group had more “very good” responses than the treatment group (66% vs 45%), and the majority of patients in both groups perceived receiving stimulation (85% in treatment group, 70% in sham group).7 Conversely, a single-blind RCT in a similar population showed full and partial response rates (based on symptom severity) of 67% and 24%, respectively, in the treatment group, vs only 0% and 6% in the sham group.8 A more recent single-blind RCT in children with dysfunctional voiding showed improvements in Dysfunctional Voiding and Incontinence Symptoms Score for both treatment and sham groups that were sustained at 2 years following completion of the treatment cycle, although the treatment group had a higher cure rate (50% cured and 20% improved, vs 20% cured and 40% improved).9 Given these mixed results, a double-blind RCT comparing PTNS, transcutaneous PTNS, and sham treatment is underway.10 A summary of studies on PTNS in children is provided in the Table.
Table. Summary of Studies on Posterior Tibial Nerve Stimulation in Children
| Study | Type | Treatment comparison | Indication for PTNS | Treatment schedule | Follow-up | Results |
|---|---|---|---|---|---|---|
| Hoebeke et al, 20024 | Prospective | PTNS only | Nonneurogenic LUTS that persisted after ≥2 y of behavioral modifications and pharmacotherapy | 30 Min weekly 20 Hz Mean 10 sessions |
After completion of PTNS cycle | Overall response 84% 43% of abnormal uroflows improved Mean bladder capacity increased |
| De Gennaro et al, 20043 | Prospective | PTNS only | Unresponsive LUTS after ≥2 y of behavioral modifications and pharmacotherapy | 30 Min weekly 20 Hz/0-10 mA 12 wk |
During and after completion of PTNS cycle | OAB: 80% improved Nonneurogenic urinary retention: 71% improved NGB: no improvement |
| Capitanucci et al, 20095 | Prospective | PTNS only | Unresponsive LUTS after 12 mo of behavioral modifications and pharmacotherapy | 30 Min weekly 20 Hz/0-10 mA 12 wk |
After completion of PTNS cycle, then every 6 mo for 2 y | 78% Symptom improvement in nonneurogenic patients 14% Improvement in patients with NGB |
| De Wall et al, 20226 | Mixed methods/retrospective | PTNS only | Nonneurogenic LUTD after median 1.5 y of mostly urotherapy and antimuscarinics | 30 Min weekly 20 Hz/0-10 mA 12 wk |
After completion of PTNS cycle | Complete response in 10%; partial response in 32% Increased average and max voided volume Improved QOL in parents and children |
| Lecompte et al, 201511 | Retrospective | Transcutaneous PTNS only | Fecal leaks ± urinary leaks despite ≥2 y of various nonoperative managements for FI, anticholinergics if needed | 20 Min daily by patient at home 10 Hz/10-25 mA 6 mo |
After completion of PTNS cycle | After completion of PTNS cycle |
| Barroso et al, 201312 | Prospective | PTNS vs parasacral TENS | Nonneurogenic OAB | PTNS: 30 min weekly 20 Hz/pulse width 400 μs 12 wk Parasacral TENS: 20 min 3×/wk 10 Hz, pulse width 700 μs 20 sessions total |
After completion of treatment cycle | PTNS: 9% symptom resolution Parasacral TENS: 70% symptom resolution DVSS scores decreased equally in both groups |
| Boudaoud et al, 20157 | Double-blind RCT | Transcutaneous PTNS vs sham | Nonneurogenic OAB despite ≥6 consecutive mo of anticholinergic medication | 30 Min twice weekly for 12 wk Treatment: 10 Hz/10 mA, pulse width 200 μs Sham: no stim |
After completion of treatment cycle | Treatment group had 5 very good (45%), 1 medium (10%), 5 poor responses (45%) Sham group had 9 very good (66%), 3 poor (33%) responses |
| Patidar et al, 20158 | Single-blind RCT | Transcutaneous PTNS vs sham | Nonneurogenic OAB unresponsive to behavioral therapy and ≥6 mo of anticholinergic medication |
30 Min weekly for 12 wk Treatment: 20 Hz/ 0-10 mA, pulse width 200 μs Sham: no stim |
After completion of treatment cycle | Treated group: 67% full response, 24% partial response Sham group: 0% full response, 6% partial response |
| Jafarov et al, 20209 | Single-blind RCT | Transcutaneous PTNS vs sham | Nonneurogenic functional voiding disorder, discontinued medical treatment due to side effects or inefficacy, off medical treatment for ≥3 mo | 30 Min weekly for 12 wk Treatment: 10-25 mA Sham: no stim |
2 Wk after completion of treatment cycle, then 2 y after | Treated group: 50% cured, 20% improved, 30% no change Sham group: 20% cured, 40% improved, 40% no change Results stable at 2 y |
| Abbreviations: DVSS, Dysfunctional Voiding Scoring System; FI, fecal incontinence; LUTD, lower urinary tract dysfunction; LUTS, lower urinary tract symptoms; max, maximum; NGB, neurogenic bladder; OAB, overactive bladder; PTNS, percutaneous tibial nerve stimulation; QOL, quality of life; RCT, randomized controlled trial; stim, stimulation; TENS, transcutaneous electrical nerve stimulation. | ||||||
We have been using PTNS for highly selected pediatric patients for almost 1 year now at the Children’s Hospital of Philadelphia. Our selection criteria include the following: refractory OAB (ie, has tried urotherapy >6 months and has failed at least 1 antimuscarinic and/or b-3 agonist, documented voided volumes <50% expected bladder capacity) and refractory dysfunctional voiding (ie, has tried urotherapy >6 months and has failed biofeedback and/or pelvic floor physical therapy). We do not routinely obtain spinal MRI or urodynamic study in straightforward cases. Patients on antimuscarinic or β-3 agonist therapy often continue those medications during PTNS treatment. Our data have yet to mature, but preliminary results are promising and mirror improvements in symptom score seen in the literature.
PTNS is a reasonable third-line option for children with persistent LUTS despite medications, behavioral modifications, and other nonsurgical approaches such as biofeedback. Although the magnitude of improvement is variable from study to study, PTNS appears to improve symptoms and objective voiding parameters in many children with 1 of 2 lower urinary tract dysfunction conditions: OAB and dysfunctional voiding. While transcutaneous PTNS provides a less invasive option, its efficacy compared to traditional PTNS has not been well established. Future studies to clarify the placebo effect, optimize patient selection, and explore long-term outcomes may help better define the role of PTNS for pediatric LUTS.
- Vaz GT, Vasconcelos MM, Oliveira EA, et al. Prevalence of lower urinary tract symptoms in school-age children. Pediatr Nephrol. 2012;27(4):597-603.
- Sayner AM, Rogers F, Tran J, et al. Transcutaneous tibial nerve stimulation in the management of overactive bladder: a scoping review. Neuromodulation. 2022;25(8):1086-1096.
- De Gennaro M, Capitanucci ML, Mastracci P, et al. Percutaneous tibial nerve neuromodulation is well tolerated in children and effective for treating refractory vesical dysfunction. J Urol. 2004;171(5):1911-1913.
- Hoebeke P, Renson C, Petillon L, et al. Percutaneous electrical nerve stimulation in children with therapy resistant nonneuropathic bladder sphincter dysfunction: a pilot study. J Urol. 2002;168(6):2605-2608.
- Capitanucci ML, Camanni D, Demelas F, et al. Long-term efficacy of percutaneous tibial nerve stimulation for different types of lower urinary tract dysfunction in children. J Urol. 2009;182(4S):2056-2061.
- De Wall LL, Bekker AP, Oomen L, et al. Posterior tibial nerve stimulation in children with lower urinary tract dysfunction: a mixed-methods analysis of experiences, quality of life and treatment effect. Int J Environ Res Public Health. 2022;19(15):9062.
- Boudaoud N, Binet A, Line A, et al. Management of refractory overactive bladder in children by transcutaneous posterior tibial nerve stimulation: a controlled study. J Pediatr Urol. 2015;11(3):138.e1-138.e10.
- Patidar N, Mittal V, Kumar M, et al. Transcutaneous posterior tibial nerve stimulation in pediatric overactive bladder: a preliminary report. J Pediatr Urol. 2015;11(6):351.e1-351.e6.
- Jafarov R, Ceyhan E, Kahraman O, et al. Efficacy of transcutaneous posterior tibial nerve stimulation in children with functional voiding disorders. Neurourol Urodyn. 2021;40(1):404-411.
- Ghijselings L, Renson C, Van de Walle J, et al. Clinical efficacy of transcutaneous tibial nerve stimulation (TTNS) versus sham therapy (part I) and TTNS versus percutaneous tibial nerve stimulation (PTNS) (part II) on the short term in children with the idiopathic overactive bladder syndrome: protocol for part I of the twofold double-blinded randomized controlled TaPaS trial. Trials. 2021;22(1):247.
- Lecompte JF, Hery G, Guys JM, Louis-Borrione C. Evaluation of transcutaneous electrical posterior tibial nerve stimulation for the treatment of fecal and urinary leaks in children: preliminary results. J Pediatr Surg. 2015;50(4):630-633.
- Barroso U Jr, Viterbo W, Bittencourt J, Farias T, Lordêlo P. Posterior tibial nerve stimulation vs parasacral transcutaneous neuromodulation for overactive bladder in children. J Urol. 2013;190(2):673-677.
advertisement
advertisement