BACKGROUND: Neuromodulation is recommended for adults with lower urinary tract symptoms (LUTS) refractory to conservative treatment. Recent evidence, suggests a role of neuromodulation in children with refractory daytime LUTS. Less is known about neuromodulation as treatment for nocturnal enuresis (NE), yet many children with refractory LUTS also struggle with NE. Here we review our experience with posterior tibial nerve stimulation (PTNS) and its effects on NE in children and adolescents in whom PTNS was started primarily for refractory OAB. We hypothesized that pediatric patients with NE would have improvement in nighttime wetting after PTNS induction.
METHODS: We have prospectively followed all pediatric patients (≤18 years old) treated with PTNS at our institution since 4/2022. Criteria for initiation of PTNS were persistent daytime LUTS despite 6-month trial of urotherapy and failure to respond to at least one antimuscarinic or beta-3 agonist. For this study, we evaluated NE scoring for all patients who completed induction of PTNS. Induction of PTNS was 12 weekly 30-minute sessions in the office. All patients fill out the Vancouver score each week. The Vancouver Score has one question that captures NE, question 7: “I wet my bed at night:” Answers are given a score of 0-4: 0=“never”; 1=“3-4 nights per month”; 2=“1-2 nights per week”; 3=“4-5 nights per week”; and 4=“every night”. Differences between initial NE score and scores at 6-week, 12-week, and last follow-up were compared using Wilcoxon-signed rank test. Logistical regression was used to identify potential factors associated with improvement in NE score.
RESULTS: Overall 28 patients started PTNS and 13 patients met inclusion criteria. Mean age at start of PTNS was 12.4 years (range 8-18years) [median age = 11.3years]. Median number of PTNS sessions for all patients was 15. Median NE symptom score was 3 at baseline, 2 at 6-week PTNS session, 2 at 12-week PTNS session, and 1 at last follow-up. Patients had a significant decrease in NE score between baseline and 12th session, and between baseline and last follow-up (both p<0.05, Figure 1). In total 8 of the 13 patients (62%) had improvement in NE score and 6 (46%) were completely dry at last follow up. Additionally, of the 5 patients who were wet every night, 2 (40%) had were completely dry at last follow up. When considering age at start of PTNS, maximum amplitude of PTNS stimulation, starting score, and type of response from PTNS (motor/sensory vs. sensory only), only type of response (sensory only) was associated with likelihood of NE score improvement.
CONCLUSIONS:
The majority of children and adolescents who undergo PTNS for refractory daytime LUTS will also have improvement in nocturnal enuresis and almost half will be completely dry after 12 weeks of PTNS. As all of these patients had additional daytime symptoms, it is unclear if PTNS would also be successful for monosymptomatic NE. Future studies are therefore warranted.
