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Posterior Tibial Nerve Stimulation For Overactive Bladder

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Percutaneous Tibial Nerve Stimulation At A Glance

Percutaneous Tibial Nerve Stimulation for Overactive Bladder
  • PTNS is a nonsurgical treatment for overactive bladder.
  • This treatment is delivered by a slim needle that is placed in the ankle where the tibial nerve is located. When the tibial nerve is stimulated, impulses travel to the nerve roots in the spine to block abnormal signals from the bladder and prevent bladder spasms.
  • No major side effects have been reported with PTNS. Patients typically describe the sensation during treatment as pulsing or tingling in the foot.
  • PTNS requires the patient to commit to 12 weekly doctor visits at the beginning, then monthly treatment afterward to sustain improvements.

Tibial Nerve Stimulator Is Safe Effective And Durable 12

Twenty-six percent of patients with overactive bladder reported continence at 12 months.

A nickel-sized tibial nerve stimulator offers overactive bladder patients with urgency urinary incontinence long-term outcomes comparable to other treatment options, including percutaneous tibial nerve stimulation.

Findings of a study published in Urology1 imply OAB treatment with the investigational eCoin device is safe and achieves a durable response, says the studys lead author, urologist Peter Gilling, MD, of Tauranga Urology Research Ltd, Tauranga, New Zealand.

The decrease in incontinence episodes and the durability of the treatment are as good as any of the other available devices and techniques for refractory urge incontinence. Sixty-five percent of patients were considered responders, which is a very competitive result, Gilling said.

And compared with other neuromodulation techniques, eCoin appears to obviate patient factors that often affect compliance, such as onerous treatment schedules, according to Gilling.

eCoin is a fully implantable device with no leads, transducers, electrodes, or control unit necessary, he said.

Like percutaneous tibial nerve stimulation, eCoin aims to relieve symptoms of overactive bladder syndrome with urgency urinary incontinence by stimulating the tibial nerve.

A urologist implants the battery-powered eCoin subcutaneously in the medial lower leg. The in-office procedure, done under local anesthesia, takes about 20 minutes.

Evaluation Of Your Urinary Incontinence

You urinary incontinence evaluation starts with a thorough history of your urinary symptoms and your overall health and other medical conditions. A pelvic exam and an in office test called bladder stress test may be done by your doctor as part of your initial evaluation.

The bladder stress test consists of observation for urinary leakage with coughing. Additional tests that may be recommended by your gynecologist or urogynecologist to further evaluate your incontinence. Not everyone needs additional testing.

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Ptns For Overactive Bladder

What is PTNS for OAB? Percutaneous Tibial Nerve Stimulation, or PTNS, is a non-surgical treatment for OAB. Medication isnt always effective against the symptoms of Overactive Bladder, and sometimes the side effects interfere with quality of life. PTNS can help reduce OAB symptoms by relaxing the bladder muscles.

How does PTNS for OAB work?PTNS therapy works by stimulating nerves through gentle electrical impulses, called neuromodulation. During the PTNS procedure, your foot is elevated and a slim needle electrode is placed by the tibial nerve in the ankle. Mild electrical impulses are sent to the sacral nerve via the tibial nerve. The sacral nerve plexus is responsible for bladder function.

PTNS can change bladder activity. You will receive a series of 12 weekly treatments that usually last 30 minutes each. After the 12 treatments, your response to PTNS will be assessed. Additional treatments may be needed to continue OAB symptom improvement.

How effective is PTNS for OAB?Studies report that between 60 and 80 percent of patients see OAB symptom improvement with PTNS. This includes reduction in the number of leakages and urgency episodes per day. Many also reported quality of life improvements.

Symptoms like these can mean youre planning your life around having access to a bathroom and no longer participating in the activities you love. You may find yourself worrying about OAB every day.

  • Bruising or bleeding where the needle is inserted

Percutaneous Tibial Nerve Stimulation Risks

Overactive bladder (OAB) affects 17% of women with incontinence

Because PTNS is a minimally-invasive procedure, there are few side effects. However, patients may experience:

  • Mild discomfort or pain at the insertion site including throbbing pain.
  • Redness, inflammation or irritation at or near the insertion site.
  • Possible bruising at the insertion site.

Not every patient is a candidate for PTNS. This procedure is not recommended for the following individuals:

  • Patients with bleeding disorder, or who are taking blood thinners.
  • Pregnant women, or those who may become pregnant during the course of treatment.
  • Patients with pacemakers or defibrillators.
  • Nerve damage or disorders If patients have diabetic neuropathy or other nerve disorders, they should discuss PTNS with their physician before starting treatment.

If you have overactive bladder symptoms and would like to discuss PTNS, contact Urology Austin to schedule an appointment with one of our urologists.

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What Does It Feel Like

Since the needle is the size of an acupuncture needle, it is not painful on insertion. We can confirm that the nerve is being stimulated appropriately by observing a toe reflex response. You may feel a tingling sensation across the foot. The intensity is then adjusted so that you only feel a slight tingling and it is not uncomfortable. In fact, many women it find it relaxing to sit for the 30 minutes, undisturbed.

What Is Posterior Tibial Nerve Stimulation

Posterior tibial nerve stimulation is a form of neuromodulation i.e. it aims to change the abnormal pattern of stimulation of the nerves that supply the bladder and pelvic floor.

Bladder and pelvic floor muscle function is co-ordinated in the lower part of the spinal cord by the sacral nerves. Electrical stimulation of the posterior tibial nerve sends a message to the sacral nerves that is thought to modify and regulate the nerves that control the bladder.

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Percutaneous Posterior Tibial Nerve Stimulation For Overactive Bladder Syndrome

Interventional procedures guidance

The National Institute for Health and Care Excellence has issued full guidance to the NHS in England, Wales, Scotland and Northern Ireland on Percutaneous posterior tibial nerve stimulation for overactive bladder syndrome. Further recommendations have been made as part of the clinical guideline on urinary incontinence in women published in September 2013. Clinical and cost-effectiveness evidence was reviewed in the development of this guideline which has led to this more specific recommendation. The interventional procedure guidance on percutaneous posterior tibial nerve stimulation for overactive bladder syndrome remains current, and should be read in conjunction with the clinical guideline.

Percutaneous Tibial Nerve Stimulation For Overactive Bladder

Percutaneous tibial nerve stimulation for overactive bladder

Percutaneous tibial nerve stimulation for overactive bladder is a minimally invasive, non-surgical treatment option for overactive bladder that helping to manage symptoms of urge incontinence, urinary frequency and urinary urgency. While PTNS may be used as a primary therapy, your doctor may use pharmacological therapies and pelvic floor muscle training to manage your symptoms of overactive bladder before administering PTNS for optimal results.

Percutaneous tibial nerve stimulation for overactive bladder is more effective and results in far fewer side effects than many OAB medications out there. Almost 80% of patients stop using OAB medicines just a year after starting, with adverse side effects accounting for 17% of discontinuation.

In cases where conservative methods arent working, PTNS is emerging as an effective treatment option for overactive bladder. Whats more, its proven efficacy has been the subject of discussion in a multitude of publications.

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Transcutaneous Tibial Nerve Stimulation

Posterior tibial nerve stimulation is given via two 50 mm×50 mm electrode pads. The live pad is placed posterior and superior to the medial malleolus and the ground pad is placed approximately 10 cm cephalad to this. Continuous stimulation at a pulse width of 200 ls and a frequency of 10 Hz is used. The amplitude was set to produce a sensory stimulus in the ipsilateral foot, at an intensity tolerable to the patient. Stimulation is given for 30 min.

Other Sites Of Electrical Stimulation

One of the first techniques for the treatment of lower urinary tract storage dysfunction stimulated the suprapubic region in patients with painful bladder syndrome , . This method was used to relieve abdominal pain, similarly to the principle of TENS when used for the relief of pain presumably. Subsequently these patients also experienced reduced urinary frequency . Two later studies documented an improvement in urodynamic parameters in patients with detrusor overactivity , sensory urgency, or neurogenic problems. However, based on the literature, the efficacy of stimulation of a suprapubic site in patients with OAB symptoms is unproven , .

Another reported approach has used stimulation of the thigh muscle in spinal cord injury patients to relieve spasticity. In some of these cases, this has led to improvements of urgency incontinence as well as an increase in the maximum cystometry capacity and reduced maximum detrusor pressure , . Further to this 6/19 patients reported clinical improvement in urinary incontinence and frequency extending out to 3 months after treatment .

Based on this, at best limited evidence for stimulation at other sites, the most logical approach to be used in transcutaneous electrical stimulation techniques appears to be either sacral stimulation or PTNS as they either directly or indirectly target the S3 spinal cord root.

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Transcutaneous Electrical Nerve Stimulation

Transcutaneous electrical nerve stimulation is carried out with surface electrodes, and therefore, provides a non-invasive alternative to other stimulation modalities. Above we described TENS of the tibial nerve. Other sites suitable for TENS include the suprapubic, sacral, penile/clitoral, vaginal, and rectal areas. Effectiveness of TENS has been demonstrated in patients with idiopathic bladder dysfunction.31 Areas of stimulation were the dermatomes of S2 and S3 and the thigh area. Stimulation frequency was 2050 Hz, and the pulse width was 200 µs. Stimulation was carried out daily during 26 weeks. Only short-term clinical improvement was shown. There are no data on long-term efficacy.

Effectiveness And Safety Of Tibial Nerve Stimulation Versus Anticholinergic Drugs For The Treatment Of Overactive Bladder Syndrome: A Meta

Transcutaneous posterior tibial nerve stimulation: evaluation of a ...

San-Chao Xiong#, Liao Peng#, Xu Hu, Yan-Xiang Shao, Kan Wu, Xiang Li

Department of Urology, Institute of Urology, West China Hospital , , China

Contributions: Conception and design: SC Xiong, L Peng Administrative support: X Li Provision of study materials or patients: SC Xiong, L Peng Collection and assembly of data: YX Shao, L Peng Data analysis and interpretation: SC Xiong, K Wu Manuscript writing: All authors Final approval of manuscript: All authors.

#These authors contributed equally to this work.

Correspondence to:

Background: This meta-analysis aimed to evaluate the efficacy and safety of tibial nerve stimulation and anticholinergic drugs for the treatment of overactive bladder syndrome .

Methods: Qualified studies up to November 3, 2020 were retrieved from PubMed, Embase, the Cochrane Library and Web of Science. Pooled mean differences were calculated to evaluate the improvement of micturition frequency per day, nocturia per night, urinary urgency episodes per day, incontinence episodes per day, and voided volume each time. Odd ratios were used to assess the discontinuation rate.

Results: A total of 6 RCTs including 291 patients were included. Comparing with those receiving ACDs, patients receiving TNS had a significantly better improvement of urge incontinence episodes , but had comparable effect on micturition , nocturia , urgency and voided volume . Moreover, TNS group had a significantly lower discontinuation rate during the trials.

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Frequency Dependence Of Tns Effects

When CMGs were stable, 30 min of stimulation at 10 Hz on the tibial nerve significantly inhibited bladder activity in the unanesthetized rats. As shown in Fig. , stimulation at 10 Hz frequency resulted in a significant increase in BC and VV to 144.1±5.07% and 147.5±4.24% of pre-stimulation respectively, as well as a significantly longer duration of effects on ICI to 135.3±4.60% of pre-stimulation. However, no significant difference in VP before and after stimulation was found. By contrast, TNS at 50 Hz resulted in a significant excitation in bladder activity after 30 min of stimulation. Though BC and VP at 50 Hz showed no change compared to the pre-stimulation results, significant decreases in both ICI and VV were observed as shown in Fig. .

Figure 1

The pre- and post-stimulation effects of the 30 min 10 Hz TNS. Representative CMG traces of pre- and post-stimulation of 30 min at 10 Hz. bladder capacity, voiding pressure, inter-contraction interval, voiding volume. The normalized data are presented as a mean with the standard error. The significance of the differences between the pre- and post-stimulation results were determined by the Students t-test .

Figure 2

Posterior Tibial Nerve And Oab

  • Percutaneous tibial nerve stimulation, requiring needle-tip electrodes which are invasive and expensive.
  • Transcutaneous tibial nerve stimulation , which requires just a basic TENS machine and standard electrodes. TTNS is much more cost effective than percutaneous tibial nerve stimulation, and much simpler to administer.

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Is Percutaneous Tibial Nerve Stimulation For Overactive Bladder Effective

PTNS is an extremely effective, low-risk treatment method that can be carried out in a typical office visit. It provides impressive results within a short duration with fewer adverse effects than medications and other neuromodulation techniques. Numerous studies have revealed that four in five people undergoing this procedure experience major recovery from their overactive bladder symptoms.

However, its imperative to go through 12 weekly sessions before assessing the effect, and top-up sessions may be needed over time. Keep in mind that PTNS is a relatively newer treatment method and its lifelong benefits are not known at this time.

Percutaneous Tibial Nerve Stimulation

Percutaneous Tibial Nerve Stimulation Relief from Overactive Bladder with Dr. Michael Douso

The posterior tibial nerve is stimulated by inserting a 34-gauge needle 45 cephalad to the medial malleolus. Once the current is applied, the flexion of the big toe or the movement of the other toes confirms the correct positioning of the needle electrode. The electrical current is a continuous square wave form with a duration of 200 Us and a frequency of 200 Hz. The intensity of the current is determined by the highest level tolerated by the patient. The stimulation sessions last for 30 min.

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How Does It Help Overactive Bladder

Overactive bladder symptoms happen when the nerve signals between your brain and bladder arent working properly. This means that your brain and bladder dont communicate the way they should, and your bladder can release urine at the wrong time.

Tibial nerve stimulation works by fixing this communication channel. The tibial nerve is part of the nerve bundle that controls the bladder. Stimulating this nerve helps control all the nerves that may not be working correctly, so your bladder only releases urine when it needs to.

An average course of tibial nerve stimulation for overactive bladder involves weekly treatment for about 12 weeks. This is followed by maintenance treatment that tapers off over time.

Tibial stimulation needs to be done in a doctors office. Although there is

60 to 70 percent of people had an improvement in their symptoms, including 47 to 56 percent who reported going to the bathroom less often.

While a normal course of tibial nerve stimulation may be 12 weeks, prolonging and tapering the treatment increases the efficacy of treatment, with about 77 percent of people reporting improvement.

However, its important to note that it can take at least six treatments before you start seeing an improvement.

Combining tibial nerve stimulation with antimuscarinics medications that relax your bladder and stop it from squeezing at the wrong time may than tibial nerve stimulation alone.

Tibial nerve stimulation can also be used in children. In a

Changes In Oab Symptoms

Eighteen participants reported a moderate or significant improvement in symptoms on the GRA. No differences were noted between responders and non-responders with regards to age, gender, diagnosis, degree of disability . Sixty-five percent of neurological patients with OAB and 36% of patients with idiopathic OAB responded to the intervention .

Table 2

Improvements were observed in both ICIQ-OAB and ICIQ-LUTSqol scores between baseline and over the course of 12 weeks treatment in both the weekly and daily arms . In the daily arm, mean ICIQ-OAB part A subscores improved between baseline and week 12 from 9.3 to 7.5 , and from 9.1 to 5.9 in the weekly arm. ICIQ-OAB part B subscores improved from 29.6 to 25.6 in the daily arm, and from 29.7 to 19.1 in the weekly arm .

Figure 3

ICIQ-LUTSqol part A subscores improved from 51 to 44.2 in the daily arm and from 44.9 to 35.9 in the weekly arm. ICIQ-LUTSqol part B subscores improved from 130.3 to 105.5 in the daily arm, and from 102.1 to 63.9 in the weekly arm .

Table 3

Improvements were also noted in the 3-day bladder diary mean. Twenty-four-hour urinary frequency improved from 11.5 at baseline to 8.8 at week 12 in the daily arm in both arms combined. And the mean number of leakages reduced from 2.5 to 1.3 at week 12 .

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Posterior Tibial Nerve Stimulation For Overactive Bladder

Posterior tibial nerve stimulation is regarded as a 3rd line treatment for patients for overactive bladder i.e. after medications and bladder retraining with pelvic floor physiotherapy have been unsuccessful in controlling symptoms.

Patient are regarding as having refractory symptoms when they have not responded to or do not tolerate at least 2 of the newer medications available for OAB symptoms.

Who Is Not A Good Fit For Ptns

Figure 5 from Management of overactive bladder review: the role of ...

Percutaneous tibial nerve stimulation is a good treatment option for both men and women suffering from OAB but it may not be the ideal treatment for everyone. If a patient has any of the following characteristics, she should not be given this treatment:

  • Has an implantable defibrillator.
  • Has nerve damage of the tibial nerve.
  • Is prone to excessive bleeding.
  • Is pregnant or planning to become pregnant during treatment.

In addition, if a patient has a pacemaker, we would need to communicate with her cardiologist to see if this is a safe treatment for her.

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