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Posterior tibial nerve stimulation for painful bladder syndrome

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Posterior tibial nerve stimulation for painful bladder syndrome

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Research question: For symptom management of Painful Bladder Syndrome (PBS), namely for pain and continence management, is Posterior Tibial Nerve Stimulation (PTNS) an appropriate evidenced-based treatment and what is the effectiveness of this treatment on pain management and functional capacity?

Date: 26/09/2022 Requestor: Lynette s22(1)(a)(ii) - irrele Endorsed by: Shannon s22(1)(a)(ii) - irrelev Researcher: Aaron s22(1)(a)(ii) - irrelevant ma Cleared by: Aaron s22(1)(a)(ii) - irrelevant ma

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  1. Contents

Posterior tibial nerve stimulation for painful bladder syndrome ………………………………………….. 1

  1. Contents ……………………………………………………………………………………………………….. 1

  2. Summary ………………………………………………………………………………………………………. 2

  3. Painful bladder syndrome ………………………………………………………………………………… 2

  4. Posterior tibial nerve stimulation ……………………………………………………………………….. 2

  5. References ……………………………………………………………………………………………………. 3

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  1. Summary

There is minimal evidence regarding the use of posterior tibial nerve stimulation (PTNS) for the treatment of painful bladder syndrome (PBS). The evidence I have found shows mixed results. The American Urological Association (AUA) allows nerve stimulation as a treatment option when other treatments have not proved effective.

  1. Painful bladder syndrome

PBS (also called bladder pain syndrome or interstitial cystitis) is a chronic pain condition characterised by pelvic pain and increased urgency and frequency of urination. PBS is a diagnosis of exclusion. Other causes of pelvic pain/urinary problems (eg. infection, medication or radiation induced injury etc.) need to be ruled out before a patient is diagnosed with PBS. There is no precise agreed definition among urologists. There are hypothesised causes but the exact aetiology is unknown. There may be more than one type of PBS. Most cases occur in women (Clemens et al, 2022; Marcu et al, 2018; Bladder Pain, 2022).

There are multiple treatment options, which may be used concurrently. Clinicians will often opt for the least invasive treatment options in the first instance. Conservative treatment options can include behaviour changes, stress reduction, changes to diet and heat/cold packs. Other treatments include physical therapy, oral or intravesical medications, surgery, botulinum toxin treatment and neuromodulation (Clemens et al, 2022; Marcu et al, 2018).

  1. Posterior tibial nerve stimulation

Posterior tibial nerve stimulation (PTNS) is a process whereby the posterior tibial nerve is stimulated using either surface electrodes (transcutaneous) or via insertion of a needle (percutaneous) (Agost-Gonzalez et al, 2021).

There is evidence that PTNS can be used as a treatment option for overactive bladder, reducing symptoms similar to those experienced in PBS. Two literature reviews have found benefits including improvement in frequency and urgency of urination and quality of life of patients. However, both reviews note limitations with the evidence including heterogeneity of studies and presence of few randomly controlled trials (Agost-Gonzalez et al, 2021; Peyronnet et al, 2019; Garcia & Periera, 2018).

Fewer studies investigate PTNS as a treatment for PBS and results of those studies are mixed. Tirlapur et al (2013) reviewed the literature on PTNS and found only a single paper assessing efficacy on PBS. This was a 2004 study that found improvements in symptom severity and quality of life. Kabay et al (2021) found a decrease in pain, frequency and urgency of urination. However, this study was small (n=39) and uncontrolled. A 2015 study found no significant changes in symptoms a 6 weeks or 12 weeks treatment using percutaneous PTNS (AUA, 2022).

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It is worth noting that the 2022 AUA guidelines for the diagnosis and treatment of PBS suggest that nerve stimulation may be an option if other treatments are not effective:

A trial of neuromodulation may be performed if other treatments have not provided adequate symptom control and quality of life improvement. If a trial of nerve stimulation is successful, then the permanent neurostimulation device may be implanted (Clemens et al, 2022, p.40).

AUA rate this guideline statement evidence level C, which is glossed as ‘low certainty’. Of particular note, this recommendation covers sacral nerve stimulation, transcutaneous electric nerve stimulation and PTNS. The evidence AUA considers regarding PTNS shows no benefit to symptoms (AUA, 2022).

  1. References

American Urological Association. (2022). Diagnosis and treatment interstitial cystitis/bladder pain syndrome. Auanet.org. https://www.auanet.org/guidelines-and- quality/guidelines/diagnosis-and-treatment-interstitial-cystitis/bladder-pain-syndrome- (2022)

Bladder pain. (2022, September 11). Pelvic Pain Foundation Australia. https://www.pelvicpain.org.au/bladder-pain/

Clemens, J. Q., Erickson, D. R., Varela, N. P., & Lai, H. H. (2022). Diagnosis and treatment of interstitial cystitis/bladder pain syndrome. The Journal of Urology, 208(1), 34–42. https://doi.org/10.1097/JU.0000000000002756

Peyronnet, B., Amarenco, G., Kerdraon, J., Cornu, J.-N., & Gamé, X. (2019). Transcutaneous posterior tibial nerve stimulation: Ready for prime time? Neurourology and Urodynamics, 38(3), 1024–1025. https://doi.org/10.1002/nau.23932

Kabay, S., Kabay, S. C., & Sevim, M. (2021). First-line treatment posterior tibial nerve stimulation in patients with interstitial cystitis/bladder pain syndrome. Central European Journal of Urology, 74(2), 208–214. https://doi.org/10.5173/ceju.2021.0372

Marcu, I., Campian, E. C., & Tu, F. F. (2018). Interstitial cystitis/bladder pain syndrome. Seminars in Reproductive Medicine, 36(2), 123–135. https://doi.org/10.1055/s-0038- 1676089

Tirlapur, S. A., Vlismas, A., Ball, E., & Khan, K. S. (2013). Nerve stimulation for chronic pelvic pain and bladder pain syndrome: a systematic review. Acta Obstetricia et Gynecologica Scandinavica, 92(8), 881–887. https://doi.org/10.1111/aogs.12184

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