The role of neuromodulation in chronic functional constipation : a systematic review

Abstract

Background : Chronic functional constipation is a highly prevalent disorder in which, when conservative measures fail to relieve symptoms, surgical interventions are sometimes indicated. In recent years, neuromodulation for the treatment of functional constipation has gained interest but its role and effectiveness are still unclear. The purpose of this review is to provide a systematic overview on the current literature on the different modalities of neurostimulation and their effect on chronic functional constipation in adults as reported in the literature. Methods : A search in the literature for articles concerning the effect of different types of neuromodulation on constipation was performed in PubMed using extensive search terms for the different modalities of neuromodulation. Studies and trials were checked for eligibility. For all types of neuromodulation together, 27 articles were included. Results : 17 studies were included on SNM (sacral nerve modulation). Although multiple studies show positive results on the effect of SNM in constipation, double-blind crossover RCT’s (randomised controlled trials) showed no significant effect. 3 studies were included for tSNS (transcutaneous sacral nerve stimulation), 2 for PTNS (percutaneous tibial nerve stimulation) and 2 for TTNS (transcutaneous tibial nerve stimulation). Studies and trials on these modalities of neuromodulation reported ambiguous results on statistical significance of the effect. For transcutaneous IFC (interferential current therapy) 2 studies were included, which both reported a statistically significant effect on all outcomes. Conclusion : The beneficial effect of neuromodulation in chronic functional constipation remains questionable. However, neuro-modulation might be worth considering in patients refractory to treatment before turning to more invasive measures. Future research should shed more light on the effects of neuromodulation in constipation.

Biofeedback pelvic floor muscle training versus posterior tibial nerve electrostimulation in treatment of functional obstructed defecation: a prospective randomized clinical trial

“…No side effects occurred in any patient in both therapeutic groups. This was similar to the literature in which BF and PTNS were considered safe physical modalities and not associated with any side effects [ 13 , 15 , 16 , 30 , 31 , 36 – 38 , 54 ].…”

“…During the neuromodulation session, the patient is completely passive. No need for any active participation of the patient during the session [ 53 , 54 ]. The effect of neuromodulation takes place in a subconscious level that the patient could not recognize it except by the observation that the OD is gradually improved [ 15 , 51 , 52 ].…”

Sakralnervmodulation in der Therapie der Stuhlinkontinenz und Obstipation: Evidenz, Programmierung und Langzeitmanagement

“…Weniger eindeutig ist die Bedeutung der SNM in der Therapie der Obstipation. Da Patienten, die aufgrund urologischer Erkrankungen behandelt wurden, eine Verbesserung der Darmmotilität unter Neuromodulation beobachteten, wurde das Konzept auch bei den verschiedenen Formen der Obstipation (Normal Transit, Slow Transit oder Auslassobstruktion) angewendet [8,45]. Obwohl viele Untersuchungen nur wenige Patienten einschließen und häufig nicht klar zwischen den verschiedenen Untergruppen der Obstipation unterschieden wird, lässt sich absehen, dass die Neuromodulation hier bei vergleichbarem Komplikationsprofil wie in der Behandlung der Stuhlinkontinenz [46] zu weit geringerer Beschwerdebesserung führt als bei dieser (▶ Tab.…”

“…Insbesondere konnten 2 doppelblinde, randomisierte Cross-over-Studien keine Wirkung der SNM belegen [47,48]. Allerdings lässt die Zusammenschau der bisherigen Studien vermuten, dass das in die verschiedenen Studien jeweils eingeschlossene Patientenkollektiv sehr inhomogen ist und möglicherweise bei Subgruppen der Patienten ein therapeutischer Effekt erzielt werden kann [45,49]. Da aufgrund der eingeschränkten Datenlage therapeutischer Benefit bei einzelnen Subgruppen der Obstipation bestehen kann und mit der Probestimulation ein kaum invasives Testverfahren zur Verfügung steht, kann nach Ausschöpfung der konservativen Behandlungsmöglichkeiten nach derzeitigem Kenntnisstand ein Therapieversuch mit der SNM in Betracht gezogen werden, insbesondere vor dem Hintergrund, dass chirurgische Alternativen sehr viel invasiver und z. T. irreversibel sind, wie z.…”

Electrical neuromodulation therapy for inflammatory bowel disease

“…SNS has proven to be a reliable method for dealing with FI in children[ 112 ]. Clinical trials have also shown that SNS can help with FI[ 113 ]. Another extensive approach conveys the benefits of SNS in patients with neuropathic FI[ 114 ].…”