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Transcutaneous Parasacral Electrical Stimulation In The Treatment Of Refractory Monosymptomatic Enuresisis: Pilot Study

Mila Torii Corrêa Leite, Camila Girardi Fachin, Fernanda Yuri Takamatsu, Marcia Emilia Francisco Shida, Renato Frota de Albuquerque Maranhão, José Luiz Martins
Pediatric Surgery of Federal University of São Paulo, Brazil

Abstract

Purpose:The transcutaneous parasacral electrical stimulation (TCPSE) has been used in lower urinary tract symptoms with good results. However, the use of TCPSE for treatment of monosymptomatic enuresis (ME) has been poorly studied. The objective of this study is to evaluate the effectiveness of TCPSE in the treatment of refractory ME.

Material and Methods:Nine children followed in the Pediatric Surgery Department of Federal University of São Paulo with refractory ME underwent TCPSE, once a week for a maximum of 12 sessions, for 30 min each and at a frequency of 20 Hz. The wet nights were evaluated by bladder diary. The treatment response was scored as non-response, partial or full response. The family also graded the improvement at the end of the treatment.

Results:Partial or full response was found in 55.5% of patients. Two children showed complete remission of enuresis after 3 months follow-up. The family assessed the treatment with high scores, even in non-response. The majority of patients showed a decrease in the volume urinated in bed. There was improvement in response in two patients after three months follow-up. None relapse of symptoms after 6 months of follow up.

Conclusion: TCPSE can be indicated as feasible treatment of refractory monosymptomatic enuresis.

Key words: urinary bladder, nocturnal enuresis, children, electrical stimulation, transcutaneous electric nerve stimulation

 

Oral presentation in 4th World Congress of the World Federation of Association of Pediatric Surgeons, Berlin, 2013


Correspondence

Mila Torii Corrêa Leite
Rua Bagé, 230 113 C
04012140 Vila Mariana- São Paulo, Brazil
Tel: (55)(11)55795709
Cel: (55)(11) 991144663
FAX: (55)(11) 55717965
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Introduction

Monosymptomatic enuresis (ME) is defined as intermittent incontinence, while sleeping, in children without any lower urinary tract symptoms (LUTS) by International Children’s Continence Society (ICCS). The currently recommended treatment such as alarms, antidiuretic hormone and anticholinergics are not effective in all ME. The transcutaneous parasacral electrical stimulation (TCPSE) has been used to LUTS with good results. However, the use of TCPSE for treatment of ME has been poorly studied. The objective of this study is to evaluate the effectiveness of TCPSE in the treatment of refractory ME.

Methods

The study was approved by the local Research Ethics Committee and conducted in strict conformity with local institutional guidelines and with international standards. Informed consent was obtained from the parents prior to the child´s inclusion in the study.

Nine children, 4 girls and 5 boys, with refractory ME underwent TCPSE in the Pediatric Surgery Department of Federal University of São Paulo from August 2011 to October 2012 and were studied prospectively. The mean age of the patients was 9,4 years, ranging from 5 to 13 years.

Inclusion criteria were: 5 years old or more, history of at least one wet night per week and failure of continuous medical treatment after at least 6 months (refractory enuresis according to the ICCS guidelines).

The criteria for exclusion were any symptoms of overactive bladder (urgency with or without urge incontinence), non-monosymptomatic enuresis and any neurological abnormality.

All patients underwent detailed clinical history to exclude the presence of LUTS, physical examination, urinalysis, lumbo-sacral spine x-ray and urinary system ultrasound. Electrical energy was produced by a generator Accurate pulse 195, LAUTZ®. Two superficial 3.5 cm electrodes were placed on each side of S3 and S2. The sessions were performed once a week for a maximum of 12 sessions, for 30 min each and at a frequency of 20 Hz. Current intensity was gradually increased until the maximum level tolerated by each child.

The wet nights were evaluated by bladder diary performed pre and post treatment. Patients were reevaluated one, three and six months after the last session. To evaluate the effectiveness of the method, the treatment response was scored according to the ICCS guidelines: Non response is defined as a 0% to 49% decrease of wet bed, partial response is defined as a 50% to 89% decrease, response is defined as a 90% or greater decrease and full response is defined as a 100% decrease of symptoms. The family also graded (score 0 to 10) the improvement at the end of the treatment.

Results

Before treatment, 5 children had wet nights every day, 2 children had 12 wet nights per month, and the other children had respectively 16 and 8 wet nights per month (Table 1).

Table 1. Pre and post treatment number of wet nigths per month in patients with Monosymptomatic enuresis treated with TCPSE. Response to treatment in percentage according to the ICCS guidelines.

PRE TREATMENT

1ST MONTH

3TH MONTH

6THMONTH

1

30

2(93,3%)

0(100%)

0(100%)

2

30

30(0%)

30(0%)

30(0%)

3

12

3(75%)

3(75%)

1(91,6%)

4

30

28(6,7%)

16(46,7%)

6(80%)

5

30

7(76,7%)

3(90%)

2(93,3%)

6

8

7(12,5%)

7(12,5%)

10(-25%)

7

30

30(0%)

30(0%)

30(0%)

8

16

4(75%)

1(93,7%)

3(81,25%)

9

12

0(100%)

0(100%)

0(100%)

Seven children were treated with oxibutinin before TCPSE for at least 6 months. Imipramine was also used in two children and only one child was unsuccessfully treated with desmopressin. There was adherence to TCPSE by families. Electrical stimulation was well tolerated by all children, with no complaints such as pain or tenderness. After 6 months follow-up, two children presented 100% improvement of wet nigths and other 4 children showed 80-93,3% decrease of symptoms. Therefore, in this pilot study, there was partial or full response in 55,55% of patients after one month and after 3 months and 66,66% after 6 months (Table 2).

Table 2. Number and percentage of patients per response to treatment after 1, 3 and 6 months.

 

1ST MONTH

3TH MONTH

6THMONTH

FULL RESPONSE

1 (11,11%)

2 (22,22%)

2 (22,22%)

RESPONSE

1 (11,11%)

2 (22,22%)

2 (22,22%)

PARTIAL RESPONSE

3 (33,33%)

1 (11,11%)

2 (22,22%)

NONE RESPONSE

4 (44,45%)

4 (44,45%)

3 (33,34)

The majority of them showed a decrease urinated volume in bed, even those partial or nonresponders. Two children showed complete remission of enuresis after one month follow-up. The families assessed the treatment with high scores (mean 7.6), even in non-responders. There was improvement in response in two patients after three months follow-up. There was no deterioration in response between the first and sixth months of follow up (Table 2). Only one patient (patient 8) had worsening of the number of wet nights during follow-up, but remained in the partial response group after 6 months of treatment (Table 1).

Discussion

Enuresis is a common condition which can cause severe psychological and social distress to children and their families [1]. The currently recommended treatment such as alarms, antidiuretic hormone, and anticholinergics are not effective in all patients, with significant relapse rate [2,6]. Electrical neural stimulation (ENS) has been used for OAB with good results in adults and in children [7-9]. Although the mechanisms of action of ENS are not fully elucidated, clinically there is improvement in urinary symptoms, in addition to modifications in the urodynamic pattern such increasing of cystometric bladder capacity and decreasing unstable contractions[10-12].

TCPSE has been shown to be more effective than sham in randomized trials in treating OAB, but has been poorly studied in treatment of ME [13]. Raheem et al [14], published a placebo controlled study of patients with severe primary ME treated with posterior tibial nerve stimulation (12 30-minute weekly sessions). After treatment, 78.6% of the patients (11/14) had a partial or full response while only 14.3% (2/14) had partial response in control group. After 3 months of follow up, full response decreased from 4 to 2 patients and the number of those with a partial response decreased from 7 to 4 patients.

A prospective randomized clinical trial was recently published using TCPSE to treat ME. The controls were treated with behavioral therapy and the experimental group was treated with behavioral therapy plus 10 sessions of TCPSE, three times weekly on alternative days. The improvement of wet nights was 61,8% in experimental group versus 37,3% in control group. None full response was observed, 15% of response, 56% of partial response and 30% of non- responders in patients treated with TCPSE [15].

In our pilot study, there was improvement in enuresis after TCPSE. Decreased urinated volume in bed was observed in most patients, which may explain the high level of satisfaction with treatment even in those children who maintained daily wet nights. The final results were quite similar to the cited researches, with less relapse of symptoms at late follow up, even with a reduced number of sessions per week in our work compared to others.

Detrusor overactivity and decreased bladder capacity are common urodynamic findings in refractory ME [16-18]. It is possible that the main role of TCPSE is to improve these urodynamic findings, decreasing wet nights. The improved response to treatment in some children and none relapse during follow-up may suggest an effective neuromodulation of TCPSE.

The main limitations of this study are the small sample size, besides the abscence of a control group. The lack of access to enuresis first-line therapy such as desmopressin and alarm (due to economic problems in our country may cause a bias in the group selected as refractory cases). Whereas the best results achieved by the first line therapy is 82% success rate with alarm and 72,8% with desmopressin and the relapse rates are respectively 12% and 50% in cases of full response, therefore TCPSE may be considered an alternative for primary treatment of monosymptomatic enuresis [19]. In future studies, the addition of urodynamic studies before and after treatment, a more detailed voiding diary as well as randomization comparing TCPSE with other treatment modalities should help to better define which patients with ME will most benefit of TCPSE.

Conclusion

TCPSE seems to be a feasible option for treatment of refractory monosymptomatic enuresis with a 66,66% rate of partial or full response.

 

 

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