Does Bladder Training Improve the Efficacy of Nerve Stimulation in Women With Refractory Overactive Bladders

Study Overview
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Brief Summary
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Overactive Bladder (OAB) is a chronic condition defined as urgency with or without incontinence usually associated with frequency and nocturia. It is a common condition affecting 15-45% of adults and constitutes a significant proportion of patients attending urogynaecology clinics. OAB is known to have a significant impact on the physical, social and emotional quality of life and sexual function in women. The treatment of OAB is initially conservative with bladder training followed by pharmacotherapy. Evidence from a recent Cochrane review on treatment of OAB suggests that the efficacy of anticholinergics in treatment of OAB is enhanced when combined with BT. Women who fail to improve with these initial measures are offered Intravesical Botox or neuromodulation in the form of Percutaneous Tibial Nerve Stimulation (PTNS) or Sacral Nerve Stimulation (SNS). PTNS has also been shown to more effective than pharmacotherapy with anticholinergics. In 2010 National Institute of Clinical Excellences (NICE) issued guidance stating 'PTNS for OAB demonstrates effectiveness without major safety concerns We hypothesise that the outcome of PTNS will improve if the PTNS sessions are combined with bladder training (BT).

Official Title
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Does Bladder Training (BT) Improve the Efficacy of Percutaneous Tibial Nerve Stimulation (PTNS) in Women With Refractory Overactive Bladder (OAB) - A Randomised Controlled Study

Conditions
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Overactive Bladder

Intervention / Treatment
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* Behavioral: Bladder Training (BT)
* Device: Percutaneous Tibial Nerve stimulation


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: All women with refractory OAB who are offered PTNS as a treatment option Exclusion Criteria: Who cannot give informed consent. Women in whom PTNS is contraindicated. This includes women who have: Gross leg oedema A pacemaker
Sexes Eligible for Study
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Female

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Active Comparator: Percutaneous Tibial Nerve stimulation<br>A needle electrode insertion site is located on the inner aspect of either leg approximately three fingerbreadths (5 cm or 2) cephalad to the medial malleolus and approximately one fingerbreadth (2 cm or ¾) posterior to the tibia. The needle electrode head is gently tapped to pierce the skin, maintaining a 60° angle, and insert to a depth of approximately 2cm. The electrode is then connected to the stimulator and the current setting needed is determined by the test mode on the stimulator. Once the current setting is known, the stimulator is started on the therapy mode which delivers the current for 30 minutes and shuts off automatically after 30 minutes. The needle is then removed and stimulator disconnected. The treatment involves twelve weekly sessions of 30 minutes each. | Device: Percutaneous Tibial Nerve stimulation<br>* A needle electrode insertion site is located on the inner aspect of either leg approximately three fingerbreadths (5 cm or 2) cephalad to the medial malleolus and approximately one fingerbreadth (2 cm or ¾) posterior to the tibia. The needle electrode head is gently tapped to pierce the skin, maintaining a 60° angle, and insert to a depth of approximately 2cm. The electrode is then connected to the stimulator and the current setting needed is determined by the test mode on the stimulator. Once the current setting is known, the stimulator is started on the therapy mode which delivers the current for 30 minutes and shuts off automatically after 30 minutes. The needle is then removed and stimulator disconnected. The treatment involves twelve weekly sessions of 30 minutes each.<br>|
| Experimental: 'Bladder Training (BT) and PTNS<br>All patients randomised to PTNS + BT group will have BT with the nurse for 20 minutes during PTNS sessions (which last 30 minutes). Since BT is recommended by NICE for a duration of 6 weeks. BT will be discussed for the first 6 sessions of the 12 week PTNS treatment cycle. | Behavioral: Bladder Training (BT)<br>* All patients randomised to PTNS + BT group will have BT with the nurse for 20 minutes during PTNS sessions (which last 30 minutes). Since BT is recommended by NICE for a duration of 6 weeks. BT will be discussed for the first 6 sessions of the 12 week PTNS treatment cycle.<br>Device: Percutaneous Tibial Nerve stimulation<br>* A needle electrode insertion site is located on the inner aspect of either leg approximately three fingerbreadths (5 cm or 2) cephalad to the medial malleolus and approximately one fingerbreadth (2 cm or ¾) posterior to the tibia. The needle electrode head is gently tapped to pierce the skin, maintaining a 60° angle, and insert to a depth of approximately 2cm. The electrode is then connected to the stimulator and the current setting needed is determined by the test mode on the stimulator. Once the current setting is known, the stimulator is started on the therapy mode which delivers the current for 30 minutes and shuts off automatically after 30 minutes. The needle is then removed and stimulator disconnected. The treatment involves twelve weekly sessions of 30 minutes each.<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Primary outcome will reduction in number of urgency episodes (bladder diary) | All patients complete a bladder diary (A record of fluid intake, voided volumes, urgency and incontinence episodes for 3 days) prior to commencement and at 3 months. | 3 months | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| reduction in frequency | Bladder diary and International Consultation on Incontinence Questionnaire - OverActive Bladder (ICIQ-OAB) questionnaire | 24 months | 
| urgency incontinence episodes | ICIQ-OAB questionnaire | 24 months | 
| increase in mean void volume | Bladder diary | 3 months | 
| improvement in quality of life and urgency scores | ICIQ-OAB questionnaire | 24 months | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Bladder training, Percutaneous Tibial nerve stimulation, Overactive bladder, Randomised controlled study