Transcutaneous Electrical Nerve

Stimulation in The Treatment of

Patients with Poststroke
Urinary Incontinence
ZHUI-FENG GUO1,* YI LIU2,* GUANG-HUI HU1 HUAN LIU1 YUN-FEI XU1
1

DEPARTMENT OF UROLOGY

DEPARTMENT OF NEUROLOGY

SHANGHAI TENTH PEOPLES HOSPITAL, TONGJI UNIVERSITY, SHANGHAI, PEOPLES REPUBLIC OF CHIN

Pembimbing:

dr. Fitri Anestherita, SpKFR

Penyaji:

Setia Wati Astri Arifin

Introduction
Urinary Incontinence (UI) is defined as an involuntary leakage of
urine, which is an independent risk factor of poststroke
prognosis.
Overall, the prevalence of UI in hospitalized patients from
different countries suggested that between 32%79% of
patients with stroke at admission experience incontinence. 1
UI seriously affects the life qualities of patients,2 and UI costs
around $11 billion US per year in home nursing in the US.3
Nearly 10,000 patients per year needed some form of therapy
in Denmark.4 Even still, this situation has not received enough
consideration in many countries.
1. Brittain KR, Peet SM, Castleden CM. Stroke and incontinence. Stroke. 1998;29(2):524528.

Introduction
Transcutaneous Electrical Nerve Stimulation (TENS)
treatment is classified as a neuromodulation
therapy.
Classically, TENS has been used in the management
of pain control6 and in the treatment of diabetic
neuropathy and Raynauds disease.7
So far, several studies have shown positive results
about this therapy in the treatment of urinary
symptoms.812
6. Long DM. Fifteen years of transcutaneous electrical stimulation for pain control. Stereotact Funct Neurosurg. 1991;56(1):219.
7. Kaada B. Vasodilation induced by transcutaneous nerve stimulation in peripheral ischemia (Raynauds phenomenon and diabetic
polyneuropathy). Eur Heart J. 1982;3(4):303314.

Introduction
A new study showed that transcutaneous posterior tibial nerve
stimulation was safe and acceptable with evidence of potential
benefit for bladder dysfunction in elders.13
Some studies reported that TENS could be used as a worthwhile
treatment for neurological patients with urinary symptoms. 8
TENS is a relatively convenient, cheap, and noninvasive therapy;
it is also free from pharmaceutical side effects. This study
prospectively investigated the effect of TENS applied to the
special group of patients with poststroke urinary symptoms. It
assessed the changes in symptom scores, quality of life, and
urodynamic variables.
Cooperberg MR, Stoller ML. Percutaneous neuromodulation. Urol Clin North Am. 2005;32(1):7178, vii.
Booth J, Hagen S, McClurg D, et al. A feasibility study of transcutaneous posterior tibial nerve stimulation for bladder and bowel
dysfunction in elderly adults in residential care. J Am Med Dir Assoc. 2013;14(4): 270274.
8.

13.

Subject and Inclusion Criteria

Patients hospitalized from
January 2010January
2011
At the Neurology
Department in the Tenth
Peoples Hospital of Tongji
University in Shanghai in
the Peoples Republic of
China

Inclusion Criteria
Patients with poststroke UI
Patients who were stable,
cooperative, and could
effectively communicate
(to accomplish therapy)
Patients who could finish
the survey on urination
and pre- and
posttreatment

Exclusion Criteria
Patients with:
Urinary retention
Various reasons for UI in the past
(Parkinsons disease, spinal cord
disease, dementia, urinary tract
Tumors, urolithiasis, unhealed
urinary tract infections, or history
of urinary tract surgery)
Severe cognitive function
disorders
Concurrent serious organic
diseases

Patients who:
Were unable to
communicate effectively
Needed massive fluid
infusion or usage of drugs
that affected urination
Were unable to provide
accurate survey
information or to complete
the treatment period

Patients and
Method
61 Treatment
patients
Enrolled patients were asked
to stop any anticholinergic
therapy at least 2 weeks
before the first visit
61 patients, divided into
treatment and control
groups
Treatment group (n=32) :
basic therapy + TENS
Control group (n=29) : basic
therapy

Method
TENS-21
Homer Ion Laboratory
Company Ltd, Tokyo,
Japan

Reusable silicone gel

electrodes with a small
amount of water was
placed in the
electrodes to make
good electrical contact

Electrode
Placement
1 Positive
electrode (39
cm2)
On the 2nd
lumbar spinous
process
2 Negative
electrodes (30
cm2) Inside the
middle and lower
third of the
junction between
the posterior

L2 spinous process

(+)

(-)
(-)

Ischial Node/Tuberosity

Method
Parameter of Treatment:
Duration of treatment 30 min
Once a day for 60 days
Pulse duration 70S
Frequency 75 Hz
Unidirectional square wave
Maximum therapeutic current 16 mA (1 k)

Evaluation
The demographic characteristics and medical
history were collected, and a detailed neurological
investigation was conducted
Pre- and post-treatment evaluation:
1. Urodynamic analysis (filling rate 20
mL/minute).
2. OverActive Bladder Symptoms Score (OABSS)
3. Barthel Index (BI)

Statistical Analysis
Statistical analysis was performed with Statistical
Package for Social Sciences, version 13 (SPSS Inc.,
Chicago, IL, USA)
Descriptive analysis was carried out using
frequencies, mean, and standard deviations
Enumeration and measurement data were
compared between groups using Chi-square test
and Students t-test
Associations were considered statistically
significant if the P value was <0.05

Results
The baseline
characteristics were
similar in both the groups,
which included:

Disease types
Diseased regions
Number
Sex
Average age
Course

None of the patients had

significant adverse effects

Lower

Improv
ed

TENS improved poststroke incontinence symptoms and

activities of daily life.

Improv
ed

TENS improved poststroke incontinence symptoms and

activities of daily life.

Bette
r

Discussion
The rehabilitation of patients with poststroke all
around the world is a challenging task
Mostly pay attention to the rehabilitation of limb
function & speech therapy
The rehabilitation of patients with poststroke UI is
still a relatively new topic, and its intervention has
not been identified as a problem by therapists
even in developed countries

Discussion
As one of the low frequency electric stimulation therapies,
TENS is used extensively in neurological rehabilitation
TENS has been a widely used therapeutic approach in acute
and chronic pain syndromes.19,20
Wong et al21 found that TENS was a convenient and
effective therapy for patients with stroke in the
rehabilitation of limb function
Hagstroem et al22 suggested TENS could improve
refractory daytime incontinence in children with overactive
bladder

Evaluatio
n
Urodynamic

 In this study of 61 patients with poststroke UI, the

basic treatment was effective in improving UI for
both groups in different degrees
However, the combination of TENS with the
basic therapy achieved significantly superior
results than in those treated with the basic
therapy alone

 Skeil et al9 : TENS to 44 neurological patients with urinary

symptoms the positive outcome of reducing the frequency
of micturition, improving bladder function, and reducing
potential renal damage, significantly changed urodynamic
variables (postvoid residual urine & volume of leaked urine)
McGuire et al23 : five of the eight patients with
miscellaneous neurological disorders, treated with TENS via
the posterior tibial or common peroneal nerves reducing
the frequency of micturition and improving bladder function
Hasan et al24 : conservative treatments using TENS and S3
neuromodulation to patients with severe refractory detrusor
instability significant changes in urodynamic parameters
and presenting symptoms

Discussion
As demonstrated by the OABSS and BI scores, there
are significant changes in detrusor function
and quality of life from the use of TENS for
these patients
Could obviously improve life for both the
patients and their caregivers
The decreasing of urinary frequency especially the
episodes of nocturia could reduce risks of falls
and their consequences.27

Conclusion
TENS improved urinary symptoms and quality of
life and decreased adverse effects in this group of
patients with poststroke UI
TENS can be recommended in this clinical
condition; however, more studies with a larger
sample size and longer follow-up are mandatory to
validate the study results

CRITICAL APPRAISAL

 Title and Background

Title
Long
Specific
Matched with contents
of the article
Didnt include time &
place

Background
Complete descriptions
Appropriate /strong
references
Purpose of the study
Previous relevance
study
No hypothesis of the
study

Patients and Methods

The authors mention:
Inclusion and exclusion
criteria
Time and place of the data
were taken
Device type & manufacturer
Intervention technique
Parameter of intervention
Theres no significant
adverse effect

The author didnt mention

clearly:
Design of the study
Randomization technique
Blinding technique
Sample size measurement
Detail of basic therapy for
both groups
The author didnt provide:
Flow diagram of the study

Results
The authors provide:
Demographic and clinical
characteristics of both
groups in table
Pre- and posttreatment
evaluation result of both
groups in table

The author didnt mention

clearly:
Detail of drop out patient

Discussion and References

Discussion
The authors mention:
Discussion about the result
Other significant studies
Strength & limitation of the
study
Study conclusion
The author didnt mention clearly:
Detail of drop out patient

References
Use Vancouver style.
Match between citation
numbers in the text &
reference list

VALIDITY
1 Was the assignment of patients to treatments
. randomised?
and was the randomisation list concealed?
2 Were all patients who entered the trial accounted
. for at its conclusion?
And were they analysed in the groups to which
they were randomised?
3 Were patients and clinicians kept blind to which
. treatment was being received?
4 Aside from the experimental treatment, were the
. groups treated equally?

Cant
tell
Cant
tell
Yes
Yes
No
Yes

IMPORTANCE
1 How precise are the results?
.
2 Do you believe the results?
.

Cant tell
Yes

APPLICABILITY
1 Do these results apply to your patient?
.
Is your patient so different from those in the trial that its
results cant help you?
How great would the potential benefit of therapy actually
be for your individual patient?
2 Are your patients values and preferences satisfied by the
. regimen and its consequences?
Do your patient and you have a clear assessment of their
values and preferences?
Are they met by this regimen and its consequences?

Yes
No
Cant tell
Cant tell
Cant tell
Cant tell

THANK YOU

Frekuensi tinggi
(Hi / Conventional TENS)
60-100 Hz
Intensitas rendah
sedikit sampai 2-3x ambang
sensorik
Frekuensi tinggi dapat
ditoleransi sampai beberapa jam

Frekuensi rendah
(Lo TENS)
0,5-10 Hz
Intensitas kuat
3-5x ambang sensorik
Frekuensi rendah kurang nyaman dan
hanya dapat dilakukan 20-30 menit

Biasanya digunakan TENS frekuensi tinggi baru kemudian

digunakan TENS frekuensi rendah yang kurang nyaman apabila
cara pertama tidak menunjukkan hasil
Jeffrey R. Basford, Electrical
Therapy, Krusen's Handbook of

 Urodynamic
Barthel Index
MMSE
Voiding Mechanism

ANATOMY, NEUROANATOMY,
PHYSIOLOGY

Loop I
Corticopontine-Mesencephalic
Nuclei
Lobus Frontal
Inhibisi parasimpatis SMC
(Loop III)
Fasilitasi pengisian kandung
kemih
Loop III
Pelvic & Pudendal Nuclei
Sacral Micturition Center
(SMC)
S2-S4
Refleks Berkemih (PS)
Regangan kontraksi
detrusor

Loop II
Pontine-Mesencephalic-Sacral
Nuclei
Pontine Micturition Center (PMC)
Koordinasi sinergi detrusor &
sfinkter

Loop IV
Motor Cortex to Pudendal Nerve
Kontrol volunter SUE
Kontraksi/Relaksasi

Lesi Loop I
Lesi supra-PMC
Stroke, TBI, hidrosefalus, MS,
tumor otak, penyakit
Parkinson)
(-) inhibisi SMCambang
batas refleks berkemih
hiperrefleks detrusor
Lesi Loop III
kapasitas bladder
Lesi pada SMC
Cedera konus/kauda, herniasi
diskus L4-L5/L5-S1, tumor,
myelodisplasia, AVM, stenosis
lumbar, arachnoiditis
(-) refleks berkemih +
disinergi detrusor-sfinkter
R.U

Lesi Loop II
Lesi pada/di bawah PMC & di
atas SMC
SCI, myelitis transversa, MS
spinal, siringomelia, tumor
medspin 1st/2nd
Hiperrefleks detrusor + disinergi
detrusor-sfinkter
Pola berkemih tdk efisien R.U
Lesi Loop IV
Myelodisplasia, stress
incontinence pada wanita dgn
lesi infrasakral & denervasi
pelvic floor, pria dgn denervasi
komplit (jarang)
Inkompetensi SUE I.U

Loop IV
Pelvic & Pudendal
Motor Cortex to Pudendal
Nuclei
Nerve
Sacral Micturition
Kontrol volunter SUE
Center (SMC)
Kontraksi/Relaksasi
S2-S4
Refleks Berkemih
(PS)
Regangan kontraksi
Loop I
detrusor
Corticopontine-Mesencephalic
Nuclei
Lobus Frontal
Inhibisi parasimpatis SMC Loop II
Pontine-Mesencephalic-Sacral
(Loop III)
Nuclei
Fasilitasi pengisian kandung
Pontine Micturition Center (SMC)
kemih
Koordinasi sinergi detrusor &

Autonomic Regulation of the Bladder

The autonomic regulation of the bladder provides a good example of the
interplay between the voluntary motor system (obviously, we have
voluntary control over urination), and the sympathetic and
parasympathetic divisions of the visceral motor system, which operate
involuntarily
The parasympathetic control of the bladder musculature, the contraction of
which causes bladder emptying, originates with neurons in the sacral
spinal cord segments (S2S4) that innervate visceral motor neurons in
parasympathetic ganglia in or near the bladder wall
Mechanoreceptors in the bladder wall supply visceral afferent information
to the spinal cord and to higher autonomic centers in the brainstem
(primarily the nucleus of the solitary tract), which in turn project to the
various central coordinating centers for bladder function in the brainstem
tegmentum and elsewhere

Loop
III
Loop
I
Loop
IV

Loop
II

Discussion
The neuroregulation of urination :
2 nerve centers (supraspinal and spinal reflex centers)
3 sets of nerves (sympathetic, parasympathetic, and somatic nerves)

These nerves arise from the lateral horn of L1L4 and S1S4, and they
are distributed in the trigone of the urinary bladder, external urethral
sphincter of the bladder neck, and transverse perineus
The conus medullaris (S2S4)
The spinal reflex center of parasympathetic and somatic nerves
promoting urination among these nerves

Important in the location of TENS electrodes

WHY IS URINARY INCONTINENCE

SUCH A GOOD PREDICTOR OF
STROKE SEVERITY?

Brittain KR, Peet SM, Castleden CM. Stroke and Incontinence. Stroke. 1998 Feb 1;29(2):5248.

Why Is Urinary Incontinence Such a Good

Predictor of Stroke Severity?
Wade and Hewer34 found in their study of
hospitalized stroke patients that both a depressed
level of consciousness and urinary incontinence in
conscious patients were related to the severity of
the stroke.
Urinary incontinence may be a good predictor of
stroke severity because of its relationship with
infarct size and intracerebral hemorrhage, but it also
may have a more subtle effect on morale and
therefore influence response to rehabilitation.
Brittain KR, Peet SM, Castleden CM. Stroke and Incontinence. Stroke. 1998 Feb 1;29(2):5248.

Why Is Urinary Incontinence Such a Good

Predictor of Stroke Severity?
Stroke is often followed by depression and feelings of apathy,
which can have adverse effects on a persons normal
voiding behavior.54
Furthermore, the relationship of urinary continence with the
central nervous system is complex.
Not only may specific centers controlling micturition be
affected but also other nonurological centers in the central
nervous system, such as those affecting speech and mobility.
These are also known to be related to outcome and are
important also for a continent state.
Brittain KR, Peet SM, Castleden CM. Stroke and Incontinence. Stroke. 1998 Feb 1;29(2):5248.

MMSE

OABSS

The Overactive Bladder Symptom Score (OABSS)

Kuisioner yang diisi oleh pasien untuk menilai
gejala OAB dgn menggunakan periode 1 minggu
sebelumnya
4 domain besar:

Berkemih harian
Berkemih malam hari (nocturia)
Urgensi
Urge UI (UUI)

The Overactive Bladder Symptom Score (OABSS)

Skor OABSS = jumlah
total skor keempat
domain
Kriteria diagnostik
OAB : > 2 poin untuk
urgensi dan > 3 poin
untuk total skor OABSS

Skor 5 = OAB ringan

Skor 6-10 = OAB
sedang
Skor 12 = OAB berat

The Overactive Bladder Symptom Score (OABSS)

Self-report questionnaire prepared by Homma et
al15 to quantify overactive bladder (OAB)
symptoms using a 1-week recall period
OABSS measures four broad domains (daily
micturition, nocturia, urinary urgency, and urge UI
[UUI]).
The OABSS score was considered as the sum of the
scores from these four domains, which were graded
with patients urination in the latest week.

BARTHEL INDEX

Barthel Index
Over the past two decades, the Barthel Index (BI) has become well-established, and it
acts as the reference standard to validate other scales.16
It has concurrent and predictive values, which can be compared with poststroke
prognosis.17
Meliputi 10 aktivitas:
Makan
Mandi
feeding; bathing; grooming; dressing; bowels; bladder; toilet use; transfers (bed to
chair and back); mobility (on level surfaces); and use of stairs.
Setiap Each item was graded into four classes using 020 points, according to whether
the patients needed help and which degree of help.
The degree of dependency was ranked as: independent (100 points); lightly dependent
(7595); moderately dependent (5070); severely dependent (2540); and totally
dependent (020).

Barthel Index (BI)

Over the past two decades, the Barthel Index (BI) has become wellestablished, and it acts as the reference standard to validate other scales. 16
It has concurrent and predictive values, which can be compared with
poststroke prognosis.17
The content of the BI questionnaire includes ten activities: feeding;
bathing; grooming; dressing; bowels; bladder; toilet use; transfers (bed to
chair and back); mobility (on level surfaces); and use of stairs.
Each item was graded into four classes using 020 points, according to
whether the patients needed help and which degree of help.
The degree of dependency was ranked as: independent (100 points);
lightly dependent (7595); moderately dependent (5070); severely
dependent (2540); and totally dependent (020).

URODYNAMIC EVALUATION

Evaluasi Urodinamik
Evaluasi urodinamik merupakan cara yang baik
untuk mengevaluasi pasien poststroke yang
umumnya mengalami gejala hiperrefleks detrusor.
Hiperrefleks detrusor menurun ketika terdapat
peningkatan kapasitas sitometri maksimum atau
penurunan tekanan akhir pengisian detrusor.
Koordinasi antara fungsi detrusor dan sfinkter uretra
meningkat ketika kecepatan aliran mencapai
maksimum.

Evaluasi Urodinamik
Merekam tekanan kandung kemih melalui transduser
tekanan intravesikal
Merekam aktivitas listrik sfinkter uretra (melalui
elektroda EMG permukaan)
Sensasi berkemih subjektif pasien terhadap pengisian
kandung kemih secara bertahap melalui uretra
dengan air/CO2

Evaluasi Urodinamik
Air lebih fisiologis, waktu pengisian lama, evaluasi
fase berkemih
CO2 poliklinik/bedside, waktu pengisian lebih
cepat, tdk dapat mengevaluasi fase berkemih
Fluoroscopic video urodynamic visualisasi
kandung kemih & uretra

Evaluasi Urodinamik - Indikasi

ISK rekuren pd pasien dengan gangguan
berkemih
Inkontinensia urine
Frequency
Retensio urine (PVR >>)
Gangguan traktus urinarius bagian atas
Monitoring tekanan berkemih
Evaluasi & monitoring obat-obatan

Evaluasi Urodinamik - Fase Pengisian

volume kk tekanan intravesikal bertahap
aktivitas EMG sfinkter uretra utk cegah kebocoran
100-200mL sensasi berkemih ringan pertama x
muncul
300-400mL sensasi berkemih sedang
400-500mL sensasi berkemih kuat (urgency)
Kapasitas maksimal kandung kemih dewasa 400
750 mL & tekanan intravesika 0 6 cmH2O ( 15
cmH2O)

Evaluasi Urodinamik - Fase Pengisian

Hiperrefleks detrusor
lesi UMN
Penurunan ambang
batas refleks berkemih
Detrusor kontraksi
mengosongkan kandung
kemih pada volume
rendah
Kapasitas pengisian kecil

Atonik/arrefleks detrusor
lesi LMN (Loop III & di
bawahnya)
Tidak menunjukkan
tekanan intravesika
meskipun kandung
kemih terisi
Kapasitas pengisian
besar

Evaluasi Urodinamik Fase Berkemih

Digunakan untuk menentukan koordinasi detrusor & sfinkter
saat berkemih
Saat berkemih normal, aktivitas EMG menghilang & terjadi
penurunan pada tekanan proksimal sfinkter uretra Inhibisi
reseptor simpatis -adrenergik yg kontraksi sfinkter uretra
Detrusor kemudian berkontraksi dan terjadi proses berkemih
Kontraksi detrusor:
Aktivasi parasimpatis dari SMC N. Pelvikus Detrusor
Supresi reseptor simpatis 2-adrenergik yg merelaksasi
detrusor

Evaluasi Urodinamik Fase Berkemih

Kontraksi detrusor & relaksasi sfinkter PMC
Normalnya (-) aktivitas EMG sfinkter selama
berkemih
Setelah berkemih, EMG menjadi aktif kembali
untuk menjaga sfinkter tertutup
Hilangnya koordinasi sinergis detrusor & sfinkter
= dissinergi detrusor-sfinkter

Evaluasi Urodinamik Fase Berkemih

Tekanan detrusor saat berkemih:

Wanita 30 cmH2O
Pria 30 50 cmH2O
Kecepatan aliran pria jika terdapat minimal 150 mL
urine :
15 20 mLH2O

Urodynamic Examination
Urodynamic examination was a good way to evaluate the
urination for patients with poststroke, and it mainly showed
detrusor hyperreflexia18 in patients with poststroke.
Therefore, detrusor hyperreflexia was decreased when there
was an increase in the maximum cystometry capacity or a
decrease in the end filling detrusor pressure.
The coordination between the function of detrusor and
urethral sphincter improved when the flow rate reached the
maximum.

Discussion
In the treatment of patients with poststroke UI, other
therapies, such as acupuncture therapy and medium
frequency electrotherapy, are also available.
However, these patients are mostly aged, 1 and a
significant number of them have a high prevalence for
diabetes or with metallic implants in vivo.
Acupuncture therapy would damage skin, and medium
frequency electrotherapy would be contraindicated for
the patients within metal internal fixation.

Discussion
Even though the results obtained in the current study are
encouraging, the outcomes presented are only for a shorter term.
It is important to know the necessity of new treatments or even
repetition of therapy over time. Hence, trials with longer follow-up
periods are recommended to confirm the long-term curative effect.
In accordance with the principle of minimally invasive treatments,
TENS is remarkably more noninvasive than acupuncture therapy
and medium frequency electrotherapy
The noninvasive aspect of this form of treatment was particularly
important in this group of patients.