Multiple sclerosis (MS) is an immune-mediated neuroinflammatory disorder of the central nervous system and is the leading non-traumatic cause for neurological disability in young and middle-aged people in the developed world. MS lesions can affect different regions of the brain and spinal cord resulting in a wide range of symptoms lower urinary tract symptoms (LUTS). It has been estimated that 80%-90% of patients with MS will suffer from LUTS over the course of the disease (1). The most common problem in patients with MS is an overactive bladder, characterized by urgency and/or urge incontinence, day/night time frequency, and may have a huge impact on quality of life. 
Percutaneous tibial nerve stimulation (PTNS) has been shown to be an effective treatment for MS-related OAB symptoms.  Transcutaneous tibial nerve stimulation is an alternative technique that involves using a TENS machine to stimulate the tibial nerve through surface electrodes   (2,3).  The technique opens up the possibility of home-based neuromodulation, however, the evidence base is rather limited.  The aim of this study is to investigate the effect of Transcutaneous Tibial Nerve Stimulation (TTNS) on OAB symptoms in MS patients.

This was a pretest-posttest study conducted at the outpatient MS clinic of a university hospital between September 2017 and March 2018. The sample consisted of 15 female patients older than 18 years old, with a diagnosis of definite MS, with no history of attack within last 1 month, with an EDSS <7 and OAB score>8, not taking antimuscarinics or taking with a stable dose. TTNS was taught to the patients by a nurse in the clinic and patients were asked to perform this at home for 30 minutes every day for 6 weeks. Patients underwent different assessments  before and after treatment, including a 3-day bladder diary, evaluation of post-void residue and validated questionnaires including Overactive Bladder Questionnaire (OAB-V8) and Qualiveen instrument. The patients were re-assessed after 6 weeks of TTNS treatment.

The mean age of the 15 women participating in the study was 42.4 (range: 28-59), 60% (n= 9) had an education below or equal to high school level and 53.3% (n=8) were married. The majority (n=12/15) had RRMS and mean duration of the disease was 11y (range: 2-35). Mean EDSS score was 3 (range:2-6) and according to the Bladder functional symptom score of the EDSS, 46.7%(n=7) experienced incontinence frequently. Duration of bladder was 7 years (range:1-35) years and 60% (n=9)  were on antimuscarinics. 
After TTNS, total OAB-V8 scores dropped significantly from 32 (range:22-39) to 22 (range:3-35) (p=0.06), Qualiveen-suip scores dropped from 2.5 (1.1-2.5) to 1.6 (0.7-3.7) (p= 0.010) and post-void residue decreased from 43 (11-82) to 15 (10-46) (p=0.001). Similarly, improvement was noted in different paramters recorded in the 3-day-bladder diary (Table 1).

After a six-weeks protocol of daily 30-minute TTNS, overactive bladder symptoms decreased and quality of life increased in MS patients.

TTNS treatment was shown to improve urinary symptoms and quality of life in MS patients reporting overactive bladder. This pilot study has shown that good outcomes can be achieved with TTNS treatment.

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