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Review ArticleOpen Access

Applicability of Parasacral Transcutaneous Electrical Nerve Stimulation in the Treatment of Overactive Bladder Volume 50- Issue 3

Lidyanne Ilídia da Silva1,2*

  • 1School of Medicine, Federal University of Juiz de Fora, Brazil
  • 2Estacio Juiz de Fora University Center, Brazil

Received: May 02, 2023;   Published: May 12, 2023

*Corresponding author: Lidyanne Ilidia da Silva, Street Professor Ernesto Evangelista, n. 80, apart 302 / bl 3SS, Juiz de Fora - MG – Brazil

DOI: 10.26717/BJSTR.2023.50.007945

Abstract PDF

ABSTRACT

Overactive bladder is defined as a syndrome whose main symptom is urinary urgency in the absence of infectious factors. It is also characterized by the presence or absence of incontinence, which may or may not be accompanied by pollakiuria and nocturia. The present study aimed to evaluate the effect of Parasacral transcutaneous electrical nerve stimulation in the treatment of overactive bladder of non-neurological origin. This is a bibliographic review through research in databases such as Pubmed, Lilacs and Virtual Health Library with the descriptors: parasacral electrical stimulation, transcutaneous neuromodulation, bladder hyperactivity, urinary urgency and Overactive Urinary Bladder, in Portuguese and English. Sixteen articles were found, involving studies that addressed parasacral transcutaneous electrical nerve stimulation in the treatment of idiopathic overactive bladder. From this review, it became possible to conclude that although previous studies clarified that parasacral transcutaneous electrical nerve stimulation is effective, in some way, for the improvement of clinical symptoms of idiopathic overactive bladder, it was not possible to standardize the best protocols, to parameters such as frequency, pulse width and current intensity, as well as the number of sessions, treatment time and frequency. However, there was a prevalence of studies using protocols with low frequency and high pulse width. Possibly, the number of weekly sessions is not a predictor of improvement.

Keywords: Overactive Bladder; Urinary Urgency; Parasacral Transcutaneous Electrical Nerve Stimulation

Introduction

Overactive bladder is a pathology of the lower urinary tract that negatively affects the quality of life of its sufferers. The main symptom for its definition is urinary urgency, in the absence of infections or other pathologies, which can be defined as a sudden irresistible desire to urinate. It is also characterized by the presence or absence of incontinence, usually accompanied by urinary frequency and nocturia [1]. The use of physiotherapy for the treatment of urinary urgency in overactive bladder has been growing more and more because it is a low cost treatment, with minimal adverse reactions, non-invasive, and can be used associated or not with drugs and surgeries [2]. In the literature, there are several studies demonstrating the effectiveness of parasacral transcutaneous electrical nerve stimulation in the treatment of overactive bladder, but there is a lot of diversity regarding the form of application, regarding the number of sessions necessary for the treatment, the number of weekly sessions, the time of application of electrostimulation, as well as the pulse width applied in therapy. Currently, the great difficulty of commuting in large cities and, mainly, the cost of this commuting for the most needy populations, hinders treatments in which the patient has to attend the health service several times in the same week. In addition, patients from smaller urban centers end up unable to receive this type of treatment. Therefore, the number of weekly sessions can reduce the patient’s adherence to treatment or even make it impossible [3]. Hence the importance of comparing the results of the protocols used in different research centers, making it possible for professionals in the field to adapt them to the daily reality of their patients. Due to the lack of standardization in the literature on treatment protocols, a bibliographical study is necessary, presenting the different theoretical currents already developed on the proposed theme, contributing significantly to the area of Physical Therapy in Women’s Health.

Methods

This work was developed from the perspective of a qualitative bibliographic study, presenting the different theoretical currents already developed by researchers related to the proposed theme. According to Gil (2006)4, qualitative research considers the interpretation of phenomena and the attribution of meanings, not requiring the use of statistical methods and techniques, and bibliographical research uses previously published material, consisting basically of books, journal articles and, currently, of information made available on the internet. To carry out this literature review, a survey of bibliographic references was carried out, through a search in databases, such as Pubmed, Lilacs and Virtual Health Library, with the following descriptors: parasacral electrical stimulation, transcutaneous neuromodulation, bladder hyperactivity, urinary urgency and Overactive Urinary Bladder, in Portuguese and English, searching for clinical studies carried out in human beings. In addition, we followed the citations of the primary references, looking for relevant articles that the database was unable to locate.

Result

Clinical studies carried out on human beings published in English and Portuguese were considered eligible. The criteria for selecting articles were those that treated idiopathic overactive bladder and its symptoms using transcutaneous parasacral electrical stimulation with analysis of clinical improvement. Studies in which overactive bladder was or was not diagnosed by urodynamic study, or by another form of evaluation, such as specific questionnaires for this purpose, were considered. Studies whose treatment was not transcutaneous (percutaneous electrical stimulation, tibial nerve stimulation, anal stimulation, vaginal/penile stimulation or implanted devices), which did not describe the parameters of frequency and/or pulse width, articles that did not were available in full and that referred to treatments for overactive bladder of neurological origin or on fecal incontinence. After the search, the duplicated results were removed and the analysis of the sample began, firstly, by the abstracts and later by the article in its entirety, in order to confirm the inclusion or exclusion of the article. Initially, a total of 244 articles were identified. After applying the exclusion criteria, 235 articles were removed and, following the citations of the primary references, seven studies were included for analysis. The results obtained, with the characterization of the studies and their interventions, are available in (Tables 1 & 2).

Table 1: Comparison between study designs.

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Table 2: Parameters used in electrostimulation.

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Discussion

Physiological Effects of Electrostimulation in the Treatment of Idiopathic Overactive Bladder

Electrostimulation consists of the use of electrical currents for the treatment of patients with different indications. The use of electrical stimulation as a treatment began in Egypt, with a species of electric eel found in the Nile River. It is known that this treatment is capable of activating peripheral, sensitive and autonomic nervous system nerve fibers [5]. Electrostimulation for the treatment of overactive bladder has been described as being used intravesically, anally, genitally, by sacral implants, transcutaneously or percutaneously (Barroso, et al. [6]). demonstrated in a meta-analysis that, while for the other methods there are only case series, the transcutaneous technique is effective at level 1 of scientific evidence. The mechanism of action of electrostimulation in the treatment of overactive bladder is still not entirely clear. It was believed that there is an improvement in the function of the bladder wall, by promoting a partial activation of denervated muscle fibers; and that transcutaneous electrical stimulation acts by modulating the micturition reflex at different points in the central nervous system. However, it was assumed that the stimulation of sacral roots is only effective when performed chronically and continuously [7]. (Lindstrom, et al. [8]) and Fall and Lindstrom [9] demonstrated through experimental studies in cats, that electrical stimulation causes activation, via reflex, of inhibitory sympathetic neurons and inhibition of excitatory parasympathetic neurons, inhibiting involuntary detrusor contractions and providing the reorganization of the central nervous system [5].

(Lisieux, et al. [10]) indicated that neuromodulation produces a physiological reconditioning effect, promoting synapse remodeling through neuroplasticity, possibly generating definitive neural reconditioning. (Dasgupta, et al. [11]) through the study of neuroimaging, verified how neuromodulation acts on the brain centers involved in bladder control. They demonstrated that its therapeutic effect is achieved due to the recovery of brain activity associated with self-regulation and attenuation of cingulate gyrus activity, reinnervating partially denervated muscle fibers. In 2009, (Lordelo, et al. [12]). described parasacral transcutaneous electrical stimulation as a continuous electrical current passing through two electrodes placed in the child’s sacral region. They reported that its mechanism of action was due to the fact that the inhibitory reflex was stimulated by low-frequency electrical impulses, causing inhibition of the detrusor muscle. Thus, (Malm-Buatsi, et al. [13]). considered transcutaneous parasacral electrical stimulation to be safe and well tolerated. Being described as a non-drug therapy, effective, non-invasive, easy to apply and low cost for public agencies [3].

Protocols and Results in the Application of Parasacral Transcutaneous Electrical Nerve Stimulation in the Treatment of Idiopathic Overactive Bladder

It can be seen that there is a wide variety of electrostimulation techniques in the literature for the treatment of overactive bladder. In the research carried out, the authors who described studies using transcutaneous parasacral electrical stimulation were: (Bower, et al. [12-26]) Of the 16 studies included, only three were composed of adults, probably because the positioning of electrodes for the treatment of urinary pathologies usually uses intracavitary spaces, through stimulation of the pudendal nerve. Although, some authors have demonstrated in their studies the undesirable effects found in intravaginal electrostimulation: vaginal irritation, infections and pain [27]. In addition, intracavitary electrodes are for individual use, which increases the cost of treatment, making it less accessible in public services or for the low-income population [5]. The duration of treatment and the number of sessions per week varied between studies. Two studies evaluated, through urodynamic studies in adults, the acute effects of the treatment, that is, the one reached immediately after the electrostimulation session. They found different results, most likely due to the difference in electrostimulation parameters (Bower, et al. [14]) used a pulse width of 200 μs and a frequency of 10 Hz, found a reduction in the maximum pressure of the detrusor, increase in the first micturition desire and, there was no alteration in the maximum cystometric capacity. While (Namima, et al. [15]), used 300 μs of pulse width and 20 Hz (10’’ on / 5’’off), not finding an increase in the bladder storage function). Six studies applied daily sessions of electrostimulation [13, 16-18, 20,24], but they differed regarding the time and parameters of electrostimulation (Table 2), which hinders the real comparison between their results. Even so, all these studies reached satisfactory results in important aspects presented in the overactive bladder (Table 1). Six studies applied electrical stimulation three times a week [12,19,21-23,26], with the same protocol of treatment (intensity at the tolerated sensory threshold, 700 μs, 10 Hz, 20 minutes of application) (Table 2). Similar results can be observed in these studies (Table 1), with emphasis on two studies in which a comparison was made between transcutaneous parasacral electrical stimulation and stimulation of the posterior tibial nerve, and with oxybutynin [22-23], showing no difference between the mentioned treatments. Two surveys repeated the same survey protocol described above, only modifying the number of weekly sessions. (Alcântara, et al. [25]) studied electrostimulation performed with two weekly sessions, while (De Paula, et al. [3]) applied electrostimulation in single weekly sessions. Both also found satisfactory results regarding the improvement of the studied symptoms. Thus, (De Paula, et al. [3]) suggested that parasacral transcutaneous electrical stimulation, associated with urotherapy, is effective in the treatment of children and that the number of weekly sessions does not suggest better use; however, he stressed that new studies with larger populations are needed to ensure these results. In view of what is presented in this review, we consider that all studies carried out indicate that parasacral transcutaneous electrical nerve stimulation is somehow effective for idiopathic overactive bladder. From the analysis of treatment parameters, it was not possible to standardize treatment protocols, since, as previously reported, some improvement was found in all studies. Thus, we suggest randomized clinical trials that compare the various electrostimulation techniques currently employed. One of the important limitations found in this research refers to the use of different nomenclatures in the studies, which, because there is no standardization of the terms, are sometimes confused with each other, making it difficult to search for studies that used the studied technique. Another limitation refers to the fact that some studies did not make the technique or parameters used clear. Even so, we consider that the findings of this study brought a great theoretical and practical contribution to the applicability of parasacral transcutaneous electrical nerve stimulation in the treatment of overactive bladder of non-neurological origin.

Conclusion

Based on this review, it was possible to conclude that although previous studies clarified that parasacral transcutaneous electrical stimulation is effective to improve the clinical symptoms of idiopathic overactive bladder, it was not possible to a standardization of the best protocols, for parameters such as frequency, pulse width and current intensity, as well as for the number of sessions, time and frequency of treatment. However, there was a prevalence of studies using protocols with low frequency and high pulse width. Possibly the number of weekly sessions is not a predictor of improvement. Thus, that conducting randomized clinical trials that compare the various electrostimulation techniques and protocols currently employed are the way to find out which methods of applying parasacral transcutaneous electrical stimulation are the most indicated therapy for the treatment of overactive bladder of origin not neurological.

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