A Urodynamic Comparison of Neural Targets for Transcutaneous Electrical Stimulation to Acutely Suppress Detrusor Contractions Following Spinal Cord Injury

Sean Doherty, Anne Vanhoestenberghe, Lynsey Duffell, Rizwan Hamid, Sarah Knight, Sean Doherty, Anne Vanhoestenberghe, Lynsey Duffell, Rizwan Hamid, Sarah Knight

Abstract

Objectives: To assess and compare the effect of transcutaneous Dorsal Genital Nerve Stimulation (DGNS), Tibial Nerve Stimulation (TNS), Sacral Nerve Stimulation (SNS), and Spinal Stimulation (SS) on Neurogenic Detrusor Overactivity (NDO) and bladder capacity in people with Spinal Cord Injuries (SCI).

Materials and methods: Seven male participants with supra-sacral SCI were tested. Standard cystometry (CMG) was performed to assess bladder activity at baseline and with stimulation applied at each site. This was conducted over four separate sessions. All stimulation was monophasic, 15 Hz, 200 μS pulses and applied at maximum tolerable amplitude. Results were analysed against individual control results from within the same session.

Results: Dorsal Genital Nerve Stimulation increased bladder capacity by 153 ± 146 ml (p = 0.016) or 117 ± 201%. DGNS, TNS and SNS all increased the volume held following the first reflex contraction, by 161 ± 175, 46 ± 62, and 34 ± 33 ml (p = 0.016, p = 0.031, p = 0.016), respectively. SS results showed small reduction of 33 ± 26 ml (p = 0.063) from baseline bladder capacity in five participants. Maximum Detrusor Pressure before leakage was increased during TNS, by 10 ± 13 cmH2O (p = 0.031) but was unchanged during stimulation of other sites. DGNS only was able to suppress at least one detrusor contraction in five participants and reduced first peak detrusor pressure below 40 cmH2O in these 5. Continuous TNS, SNS, and SS produced non-significant changes in bladder capacity from baseline, comparable to conditional stimulation. Increase in bladder capacity correlated with stimulation amplitude for DGNS but not TNS, SNS or SS.

Conclusion: In this pilot study DGNS acutely suppressed detrusor contractions and increased bladder capacity whereas TNS, SNS, and SS did not. This is the first within individual comparison of surface stimulation sites for management of NDO in SCI individuals.

Keywords: bladder; electrical stimulation; incontinence; neurogenic detrusor overactivity; neuromodulation; spinal cord injury.

Copyright © 2019 Doherty, Vanhoestenberghe, Duffell, Hamid and Knight.

Figures

FIGURE 1
FIGURE 1
To stimulate the dorsal genital nerve (a), electrodes were placed on the dorsum of the penile shaft. 1 cm paddle electrodes (Ambu Neuroline 710) were placed approximately 2 cm apart, the cathode was placed proximally. Tibial nerve electrodes (c) were 2.5 cm round surface electrodes (PALS) placed unilaterally 1 cm posterior and approximately 3 cm superior to the medial malleolus (cathode) and approximately 5 cm superior (anode). Sacral electrodes (b) were 5 × 5 cm (PALS) electrodes placed over either side of the sacrum, at the level determined to be over the S3 foramina through manual palpation of the sacrum. Spinal stimulation (d) used 5 cm circular and 7.5 × 10 cm electrodes (PALS) over T11-12 and the abdominal areas, respectively (Hofstoetter et al., 2014).
FIGURE 2
FIGURE 2
Outcome measures shown on a cystometry detrusor pressure trace, from a DGNS trial fill. Volume infused is taken as the outcome at the time point indicated on the pressure trace for Reflex Volume (RV) and End Fill Volume (EFV). VtL, Volume to Leakage; FPDP, First Peak Detrusor Pressure; MDP, Maximum Detrusor Pressure. An example of a suppressed detrusor contraction is highlighted.
FIGURE 3
FIGURE 3
(A) Boxplot of end fill volume and (B) Maximum Detrusor Pressure change from baseline for each site. Boxes show median, interquartile ranges, and error bars denote the range. Stars denote that change from baseline is p < 0.05 following a Wilcoxon Rank Sum test. (C) Amplitude of stimulation vs. change in Volume to Leakage (VtL) for each site. DGNS appears to deliver increased gains when applied at greater amplitudes (R2 = 0.75). (D) Changes from baseline in end fill volumes (EFV) in continuous (green) and conditional (white) stimulation fills. Boxes represent the median and interquartile range of within session changes in EFV, whiskers show the range. (E) Individual changes in VtL as mean values obtained during control and conditional stimulation fills from each session.
FIGURE 4
FIGURE 4
Participant 5 TNS session results. First reflex detrusor contraction (RV) and End Fill Volume (EFV) are shown for each fill in the session. Following the first conditional TNS fill, a noticeable change in volume prior to the first detrusor contraction was seen in each subsequent fill both with and without stimulation.

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