|Year : 2019 | Volume
| Issue : 4 | Page : 98-101
Transcutaneous posterior tibial nerve stimulation for fecal incontinence: New hope revisited
Ahmed A Khalil, Essam F Ebeid, Tarek Y Ahmed, Karim F Elneklawy, Mohamed A Nada
Departments of General and Colorectal Surgery, Ain Shams University, Cairo, Egypt
|Date of Submission||10-Sep-2019|
|Date of Decision||10-Oct-2019|
|Date of Acceptance||10-Nov-2019|
|Date of Web Publication||27-Dec-2019|
Dr. Ahmed A Khalil
Department of General and Colorectal Surgery, Ain Shams University, 7 Ibn Qotaiba Street- 7thDistrict, Cairo
Source of Support: None, Conflict of Interest: None
Background: Neuro-modulation of the pelvic nerves is an effective and promising modality for treating fecal incontinence. Direct sacral nerve stimulation is the most popular for neuro-modulation although it is technically demanding. Percutaneous and transcutaneous posterior tibial nerve stimulations are relatively newer approaches for neuro-modulation and they carry the advantage of being cheaper and less invasive. There is not much published data about the transcutaneous approach and in this study, we are describing our experience with this technique. Objective: This study was conducted to describe and determine the efficacy of percutaneous posterior tibial nerve stimulation in the treatment of fecal incontinence. Design: A prospective descriptive study. Setting: The colorectal clinic in the hospital was prepared with the required equipment. The authors funded all procedures performed and the patients paid no extra charges. Patients and Methods: Our study included 15 patients with fecal incontinence visiting the colorectal clinic in Ain Shams University Hospital. All patients received 12 sessions of electric stimulation, 3 sessions per week for 40 minutes each. Main Outcome Measures: Sample Size Wexner score and the short term effect of the treatment. Sample Size: 15 patients. Results: The study included 11 females and 4 males, 2 patients were excluded from the results. The results showed that there was improvement in mean Wexner score for these patients from 13 before the treatment to 8 after finishing the treatment course. Reassessment after 6 months of treatment revealed no deterioration in their continence. Conclusion: We found that transcutaneous posterior tibial nerve stimulation is an effective, cheap, and tolerable method for treating fecal incontinence. However, long-term follow up is required on larger group of patients to adopt this technique. Limitations: Small sample size, short course follow up.Conflict of Interest: None.
Keywords: Fecal incontinence, nerve stimulation, posterior tibial nerve stimulation
|How to cite this article:|
Khalil AA, Ebeid EF, Ahmed TY, Elneklawy KF, Nada MA. Transcutaneous posterior tibial nerve stimulation for fecal incontinence: New hope revisited. World J Colorectal Surg 2019;8:98-101
|How to cite this URL:|
Khalil AA, Ebeid EF, Ahmed TY, Elneklawy KF, Nada MA. Transcutaneous posterior tibial nerve stimulation for fecal incontinence: New hope revisited. World J Colorectal Surg [serial online] 2019 [cited 2020 Apr 9];8:98-101. Available from: http://www.wjcs.us.com/text.asp?2019/8/4/98/274287
| Introduction|| |
Fecal incontinence is a multimodal issue with social and health impacts as well. The prevalence of major incontinence in adults is estimated to be 1.4%. Unfortunately in Egypt, there are no accurate records for the number of patients suffering from fecal incontinence; however, it is obviously a problem that is encountered on a daily basis in any specialized colorectal clinic.
Initial treatment options for fecal incontinence are conservative measures, including dietary control, constipation medications, biofeedback, and pelvic floor exercises. Nevertheless, conservative treatment is not usually effective to improve fecal incontinence. Neuromodulation of the pelvic nerves is considered the second line of treatment for fecal incontinence.
Neuromodulation techniques were first described in the 90s. Direct neuromodulation via sacral nerve stimulation (SNS) is the most popular modality used, and it carries the best results in achieving long-term fecal control. However, this technique is expensive, requires well-trained medical personnel in a specialized center, as well as being invasive and permanent, which may not be suitable for all patients.
Other methods of neuromodulation have evolved that are less invasive and less technically demanding than SNS. These include percutaneous posterior tibial nerve stimulation (PPTNS) and transcutaneous posterior tibial nerve stimulation (TPTNS). They can be performed on an outpatient basis with a reduced financial burden.
There is paucity in the number of studies evaluating or comparing these techniques in terms of their impact on achieving and maintaining continence. Our study aims at evaluating our initial experience with TPTNS and reviewing short-term outcomes of this novel technique.
| Patients and Methods|| |
Our study is prospective. Following the inclusion criteria, we recruited patients with fecal incontinence from the colorectal clinic at the Ain Shams University Hospital between October 2016 and October 2017. We conducted the procedure in the clinic on an outpatient basis. The institutional review board (IRB) on ethical considerations approved this study. All participating patients were informed about the study and they signed informed consent to prove their knowledge and acceptance of participation.
- Patients with fecal incontinence for at least 3 months that was defined as at least one episode of incontinence on average per week
- Failed conservative measures
- More than 18 years of age
- Able to give consent and understand the procedure.
- Patients with congenital anorectal malformation
- Previous colorectal resection
- Previous pelvic irradiation
- Rectal prolapse
- External anal sphincter defect exceeding 90° in circumference
- Implanted pacemaker or defibrillator
- Pregnant or intention to become pregnant
- Neurological disease (in <6 months)
- Chronic diarrhea
- Inflammatory bowel disease (IBD).
All patients were subjected to:
- A full and thorough history
- Digital rectal examination
- Endo-anal ultrasound to assess the sphincters
- Wexner score prior to treatment
- Wexner score assessment at the end of the treatment.
We provided 12 stimulation sessions, in which 3 sessions per week were delivered through two surface electrodes. The negative electrode was placed behind the medial malleolus while the positive electrode placed 10 cm proximal to it. Correct positioning was determined by the hallux reaction. Stimulation protocol was a fixed frequency of 10 Hz and pulse width of 200 ms in continuous mode for 40 min. Stimulation intensity was determined by participant comfort level.
| Results|| |
Our study included 15 patients, of which 11 (73%) were females and 4 (27%) were males. The age range of the participants, included in the study, was 25 to 58 years. Two patients were excluded from our study. One patient was excluded because of failure to comply and the second patient developed a rash at the site of the adhesive pads.
Eight patients had a history of previous anal surgery—five patients had hemorrhoidectomies and three patients had anal fistula surgery. Concerning the obstetric history, nine patients had a vaginal delivery, five had perineal tears, and not enough data for the other four patients were found. At the time of inclusion, the mean Wexner score was 13. After completion of the treatment, the mean Wexner score was 8 [Figure 1]. After 6 months, patients were reassessed, and we found no deterioration in their continence.
| Discussion|| |
Fecal incontinence is an annoying health problem of variable etiologies that affects the quality of life (QoL) of the patients. Nerve stimulation techniques are recent trends evolving for the treatment of fecal incontinence, especially for those patients who failed to achieve improvement with conservative measures. SNS is known to be effective in many cases of incontinence; however, it has some drawbacks. The drawbacks of SNS are that it is an invasive maneuver, relatively expensive, and requires hospitalization.
In this study, we discussed our early experience in the modified technique for nerve stimulation, which is TPTNS. There is scarcity in the published data about this technique as it is still in the assessment phase. We were particularly enthusiastic about this technique because it carries the advantages of being noninvasive, cheap, and can be conducted as an outpatient procedure (as we did in this study) or even at home.
Thirteen of the fifteen recruited patients (11 F, mean age 41) were able to complete the study. We did unilateral TPTNS. We offered 12 sessions for each patient, three sessions weekly for 40 minutes each. There is a consensus that patients need 12 sessions of nerve stimulation to show improvement. However, there is variability in the frequency of sessions per week in literature. Shafik et al. reported the same regimen as we did. Other studies reported only one session per week for 12 weeks. George et al. and Thomas et al. described two sessions per week for 6 weeks. It is believed that the less the period of treatment, the more the compliance of patients is and that is why we preferred to conduct our study in 4 weeks.
All our patients were assessed before and after the 4 weeks treatment course. We used the Wexner score to evaluate the effectiveness of our strategy and found that the mean Wexner score before treatment was 13 and after completion of the treatment improved to 8. This means that our regimen showed a good response for the patients in terms of decrease in fecal incontinence episodes and QoL. In addition, there was an improvement of symptoms in 54% of the patients, which was assessed by a visual analog scale.
There are many studies conducted to assess and compare SNS and PPTNS. Nevertheless, the studies evaluating the transcutaneous nerve stimulation are few. This is because it is considered a novel technique.
Moya et al. published a study comparing both SNS and PPTNS in 19 male patients suffering from fecal incontinence. They also used the Wexner score to assess the efficacy of both modalities. They found that SNS significantly improved the mean Wexner score from 14 to 4. PPTNS improved the mean Wexner score from 12 to 5, which was significant. However, there was no significant difference between both techniques, and these results are comparable with ours in this study.
Another study published by Thin et al. also compared SNS and PPTNS in 40 patients—23 for SNS and 17 for PPTNS—using the Cleveland Clinic Incontinence Score. The score was measured at baseline and at 3 and 6 months of follow-up, and it was found to be 16.2, 11.1, and 10.4 for SNS vs 15.1, 11.7, and 12.1 for PPTNS.
Among the few studies evaluating the transcutaneous nerve stimulation was the study reported by Takano which included 75 patients who received sessions of bilateral posterior tibial nerve stimulation. The mean Wexner score for the patients decreased from 10.2 to 6.9 which was a significant difference. That was comparable to our results.
In another study, George et al. conducted transcutaneous nerve stimulation on 11 patients in a randomized controlled trial (RCT) and showed a reduction in at least 50% of the weekly episodes of fecal incontinence at the end of the 6 weeks study course.
Thomas et al., studied bilateral nerve stimulation on 20 patients, 17 of them completed the treatment course. Two patients achieved complete continence and ten (59%) showed a <50% reduction in incontinence episodes. These patients had a significant improvement in the ability to defer defecation from 3 to 5 min, which was statistically significant.
Our patients were followed up for 6 months and they did not show deterioration in the achieved results. Other studies followed the patients for 6 months or until the patients returned to the prestimulation state. However, this is considered one of the main limitations of our study as long-term follow-up with larger sample size is required for accurate evaluation of the described technique.
| Conclusion|| |
Transcutaneous posterior tibial nerve stimulation appears to be an effective, cheap, safe, and tolerable method for the treatment of fecal incontinence. However, further studies and long-term follow-up are required for full assessment of this technique.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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