[version 1; peer review: 1 approved with reservations, 1 not approved]
No competing interests were disclosed.
Efforts to combat the symptoms of incontinence have been made over the past decades, yet difficulties still remain. In this case study, we reported the case of a patient with urinary incontinence comorbid with major vascular neurocognitive disorder who received repetitive transcranial magnetic stimulation (rTMS) on the bilateral paracentral lobule. After five sessions of rTMS, the patient was fully aware of her urination, but her neurocognitive decline did not improve at all.
To the best of our knowledge, there are no reports of treating urinary incontinence with major vascular neurocognitive disorder through rTMS on bilateral paracentral lobule. In this case of urinary incontinence with major vascular neurocognitive disorder, no therapeutic effects were found of intravenous levofloxacin and pelvic floor electrical stimulation. After applying rTMS on the bilateral paracentral lobule, therapeutic effects had presented in the first rTMS session. Here we reported this case for peer discussion.
A 67-year-old female Chinese Han farmer suffered from urinary incontinence over two weeks. She had received intravenous levofloxacin (
At admission, she was aware but had little interaction with her surroundings. A significant decline in most cognitive domains was found. She had difficulty making out others’ words, and her sentences were hard to understand. Her recent memory was heavily impaired. She hardly made decisions or planned instrumental activities. She scored seven on the mini-mental state examination (MMSE) test with partially preserved language. Her clock drawing task scored therewith only irregularly rounded shape and several numbers out of circle. Her clinical dementia rating (CDR) test score was two.
The routine blood tests were normal. The urine routine test showed no inflammatory variation. Serum liver function, kidney function, electrolytes and homocysteine were normal. Serum triglycerides and total cholesterol were elevated to 4.83 mmol/L and 7.0 mmol/L, respectively. Fasting plasma glucose was normal, while serum glycosylated hemoglobin was increased up to 7.2%. Serum thyroid-stimulating hormone, free triiodothyronine and free tetraiodothyronine were normal. Serum vitamin B12 decreased to 129.0 pg/ml. The serum was negative for antibodies against hepatitis C, syphilis, and AIDS. Electrocardiography showed sinus rhythm with no abnormalities in QRS intervals or QT intervals or ST-T changes. Chest computed tomography examination manifested as chronic bronchitis. Color Doppler ultrasound examination of the heart, digestive system, urinary system, and carotid vertebral artery was normal. Magnetic resonance imaging (MRI) of the brain showed patchy lesions around the lateral ventricle and scattered point lesions in the basal ganglia, corona radiata and frontal and parietal subcortical white matter, with features of hypointensity on T1-weighted images and hyperintensity on T2-weighted images. Mild frontal and temporal atrophy were detected, while the midbrain, pons and medulla were retained. Magnetic resonance angiography (MRA) detected carotid and intracranial atherosclerosis with no significant local stenosis.
According to the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5), we diagnosed the case as probable major vascular neurocognitive disorder. The most pressing issue was urinal incontinence.
The patient received treatment with repetitive transcranial magnetic stimulation (rTMS). A B65-type figure-eight coil connected to a MagPro X100 stimulator (Magventure Inc.) was used. Resting motor threshold (RMT) was determined by standard methods and not repeated during the treatment course. Active treatment was delivered at 90% RMT intensity. Stimulation was administered at 20 Hz with 25 stimulation trains of 30 stimuli each with a 30-second intertrain interval. The hot spot of stimulation was located at the bilateral paracentral lobule. In addition, intramuscular injection of vitamin B12 and oral medications to control blood sugar and cholesterol were carried out during the rTMS intervention.
The symptom of urinal incontinence was markedly improved since the third rTMS therapeutic day. After a five-day course of rTMS intervention, the patient reported full awareness of her urination. Another two five-day courses of rTMS were administrated, her urinal incontinence did not relapse but her neurocognitive decline had not improved at all. The scores of MMSE and CDR were the same as before treatment.
In this case, an elderly female patient suffering from urinal incontinence had received intravenous antibiotics and pelvic floor electrical stimulation for a week before her admission, but little therapeutic effect was produced. After her admission, high-frequency rTMS on the bilateral paracentral lobule was conducted, and her urination function recovered in one week. During the two weeks of rTMS treatment, the symptom of urinal incontinence disappeared without any fluctuation. Therefore, we speculated that rTMS in cortical urologic centers is useful for the remission of urinary incontinence.
According to the definitions from International Continence Society Standardization of Terminology reports,
To relieve symptoms of urinary incontinence, many methods have emerged in past decades, such as physiotherapy, psychological care, manual assistance, behavior therapy, drug therapy, urethral catheterization, and surgical treatment.
rTMS was also attempted to treat urinary incontinence. Yani
Through administrating a series of impulses at specific intensity and frequency on selected brain cortex,
After all, there were several factors that could be attributed to the recovery of the patient’s urinal incontinence. Firstly, that vitamin B12 supplementation and professional nursing care might help to improve the patient’s urinal symptom. Secondly, the clinical manifestation of vascular neurocognitive disorder tends to fluctuate, so, the urinal incontinence symptom may disappear along with the temporarily relief of vascular neurocognitive disorder. Thirdly, intravenous levofloxacin and pelvic floor electrical stimulation before admission might have an effect on the mitigation of urinal symptoms. Whatever, the patient’s urinary incontinence began to recover and disappeared just after rTMS treatment was added. For rTMS we focused on the bilateral paracentral lobule, which is the cortical center of urination. So we regarded that rTMS being applied to the bilateral paracentral lobule could be used for treating urinary incontinence in patients with major vascular neurocognitive disorder. More clinical case collections and controlled trials are needed to verify this result.
Written informed consent for publication of their clinical details was obtained from the daughter of the patient.
All data underlying the results are available as part of the article and no additional source data are required.
We thank AJE (
Thank you for inviting me to review the case. The authors introduced an interesting case for resolving the urinary incontinence in major vascular neurocognitive disorder by the repetitive transcranial magnetic stimulation (rTMS). The case actually provided a new idea and method for the major clinical issue. Authors need to address the following concerns before acceptance for indexing.
1) Abstract: "Many efforts had been made to combat the symptoms of incontinence over the past decades, yet difficulties still remain", the incontinence should be clarified as urinary incontinence;
2) Abstract: there are a lack of treatments before rTMS;
3) Abstract: the conclusion was too absolute since a case was obviously not for a clear result and further studies are still needed.
4) Introduction: the paragraph 1 of the section was almost Duplicated with Abstract. The therapeutic effect was not discussed in the INTRODUCTION. The authors should introduce the conventional method for treating urinary incontinence and emphasized the necessity of rTMS;
5) ethical consent should be added in the section of case report.
Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes?
Yes
Is the case presented with sufficient detail to be useful for other practitioners?
Yes
Is sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment?
Yes
Is the background of the case’s history and progression described in sufficient detail?
No
Reviewer Expertise:
perioperative neurocognitive disorders; surgery; tDCS; elderly patients; postoperative delirium
I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.
Dear Penghui Wei,
We would sincerely thank you for your time and effort that you have put into reviewing the previous version of this manuscript. Your suggestions have enabled us to improve our work.
According to your nice suggestions, we have made extensive corrections to our previous draft and the detailed corrections are labeled on the new version of the manuscript which we hope to meet with approval.
For details about the corrections according to your suggestions, here we list them as follows.
1) Firstly, as a matter of fact, we did not obtain ethical consent before starting the rTMS. However, we did all of the treatment on patient according to our clinical team decision and oral consent from the patient’s family. Since rTMS were used in patients of almost all kinds of disease and were proven to be a safe therapeutic way in the past decades, we were not asked to obtain ethical consent before starting rTMS from Ethic Committee of our hospital. Hope you accept our irretrievable deficiency.
2) Secondly, the ABSTRACT and INTRODUCTION have been rewritten that would be matched to the criterion of medical thesis in our perspective.
3) Thirdly, we have rephrased some sentences adopting your sensible suggestion.
Thank you a lot for your sincerely instructions which would help us to improve our abilities in clinical practice and research work. Hope you kindly accept our new version.
Yours sincerely,
Yuangao Liao.
Department of neurology, Huanggang Center Hospital, Huanggang, Hubei, China.
Abstract is not connected to the case report. Especially the introduction requires rephrasing of some statements required. i.e. ‘To stimulate the cortical urination centre might theoretically be useful for regulating urination process.’ The background last sentence. In this case of urinary incontinence with major vascular neurocognitive disorder, repetitive transcranial magnetic stimulation (rTMS) on the bilateral paracentral lobule was applied and therapeutic effect was obvious.’ is best suited to conclusion.
Case report: Introduction needs rewriting, raising the importance of addressing incontinence in both ageing and people with dementia. This needs to be better documented, and concentrating on introducing the importance of the topic, and therapeutic issues around it. I would suggest the authors to avoid sentences that do not add much to the text, i.e. ‘Efforts to combat the symptoms of incontinence have been made over the past decades, yet difficulties still remain.’ If using such statements, please rephrase it and document it.
The second part of the introduction is part of the discussion/conclusion, and not introduction.
The case report needs to be better structured I wonder why authors did not exclude hypoactive delirium as one of he differential diagnosis? Vitamin B12 deficiency can lead to delirium and authors’ discussion points towards its regulation contributing to improvement in both physical and mental state. There is not documentation of CRP, or the reasons why patients required inpatient admission (the latter points towards seriousness of patient’s physical state), or when the Vitamin B12 blood levels were normalised, i.e. whether this coincided with regulation of urine incontinence. Also, why implementing rTMS before physical state is normalised? Was the patient assessed for delirium with CAM or AT4?
The case presentation and discussion indicate that the use of rTMS in this case are highly speculative, with other studies conducted in this areas requiring further confirmation.
Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes?
No
Is the case presented with sufficient detail to be useful for other practitioners?
No
Is sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment?
No
Is the background of the case’s history and progression described in sufficient detail?
No
Reviewer Expertise:
dementia, Alzheiemr's disease, treatment, diagnosis
I confirm that I have read this submission and believe that I have an appropriate level of expertise to state that I do not consider it to be of an acceptable scientific standard, for reasons outlined above.
Dear Elizabeta B Mukaetova Ladinska,
We would sincerely thank you for your time and effort that you have put into reviewing the previous version of this manuscript. Your suggestions have enabled us to improve our work.
According to your nice suggestions, we have made extensive corrections to our previous draft and the detailed corrections are labeled on the new version of the manuscript which we hope to meet with approval.
For details about the corrections according to your suggestions, here we list them as follows.
1) Firstly, the ABSTRACT have been rewritten in which some statements was rephrased and the last sentence of BACKGROUND was been substituted into CONCLUSION.
2) Secondly, almost all of the INTRODUCTION have been rewritten that would be matched to the criterion of introduction in our perspective.
3) Thirdly, that we did not make differential diagnosis about hypoactive delirium in part of CASE REPORT was an irreparable deficiency. The reason that we did not assess the patient with CAM or AT4 was that we had experientially excluded the diagnosis of delirium at our first glance. In fact, we might do more to improve our scientific strictness when preparing an academic report.
4) Fourthly, it was about the effect of vitamin B12 supplement on patient’s psychiatric status. We had mentioned in the last paragraph of DISCUSSION that all other symptoms except for urinary incontinence did not alleviate at all. Based on this, we speculated that vitamin B12 supplement did not effect on urinary incontinence improvement in our observational period.
5) Lastly, there were others questions in part of CASE REPORT such as documentation of CRP, reasons of inpatient admission and implementing rTMS before physical state normalized. We hardly make comprehensive explanations to them, but we declare that we did those clinical practices according to our team decision and oral consent from the patient’s family.
Thank you a lot for your sincerely instructions which would help us to improve our abilities in clinical practice and research work. Hope you kindly accept our new version.
Yours sincerely,
Yuangao Liao.
Department of neurology, Huanggang Center Hospital, Huanggang, Hubei, China.