Posterior Tibial Nerve Stimulation Works for Overactive Bladder
Abstract & Commentary
By Frank W. Ling, MD, Clinical Professor, Departments of Obstetrics and Gynecology, Vanderbilt University School of Medicine, and Meharry Medical College, Nashville, is Associate Editor for OB/GYN Clinical Alert.
Dr. Ling reports no financial relationships relevant to this field of study.
Synopsis: Posterior tibial nerve stimulation is effective treatment for overactive bladder in patients who fail anticholinergic medication, with most patients improving within 6 weeks.
Source: Leong FC, et al. Posterior tibial nerve stimulation in patients who have failed anticholinergic therapy: Efficacy and time to response. Female Pelvic Med Reconstr Surg 2011;17:74.
In a retrospective chart review at a single university urogynecology practice between 2000 and 2009, the authors identified 197 patients who underwent posterior tibial nerve stimulation (PTNS) after failing medical therapy for overactive bladder (OAB) with anticholinergic medication. Exclusion criteria included patients with primary pelvic pain, interstitial cystitis, detrusor hyperreflexia, incomplete bladder emptying, and either successful or lack of anticholinergic therapy. All patients had significant urgency, frequency, and nocturia. All patients had to have failed one or more anticholinergic agent that had been taken for a month or longer. Any patient who continued to complain of urgency, frequency, and/or nocturia despite oral medication was offered PTNS treatment in the form of weekly sessions. The inclusion requirements of a minimum of a month of treatment of at least one anticholinergic medication were used to ensure that medical treatment was truly inadequate. Ultimately 141 patients met criteria for inclusion in the study. The mean number of medications tried was 2.5. The median week for improvement as reported by the patients varied for different symptoms: frequency (7 weeks), urgency and urge incontinence (6 weeks), and nocturia (5 weeks). Ninety-five (67.4%) patients were satisfied with their improvement in OAB symptoms using PTNS.
Commentary
I'll bet that if you've been listening to your patients, you've been hearing about overactive bladder. I also bet that if you've been asking patients who don't specifically complain of urgency, frequency, and nocturia, that they have been saying things like "Yeah, I have that. It bothers me, but I just thought that was normal." It is estimated that OAB occurs in one out of six adults. Treatments excluding oral medication include pelvic floor training, restriction of dietary fluids, and avoidance of food irritants. Even though multiple medications are now available (e.g., Ditropan, Detrol, Vesicare, Enablex, Sanctura, Toviaz, and Gelnique), adverse effects or lack of efficacy limit their use. So that's where PTNS comes into play.
Available since 2000, it can be used alone or as an adjunct to medical therapy. Also known as Urgent PC, the devices are manufactured by Uroplasty, Inc. The procedure is simple enough: A 34-gauge needle electrode is inserted into the leg approximately 5 cm superior to the lateral malleolus directed cephalad at a 60-degree angle. The ground electrode is placed on the ipsilateral instep. Amplitude of the stimulus is increased until there is a motor response (great toe plantar flexion). The treatment lasts 30 minutes and is repeated weekly.
The purpose of reviewing this abstract isn't because it's great science (since it's a retrospective review, the study design is flawed), or because office Urgent PC is lucrative (it is both codeable and reimburseable), or because Urgent PC will radically change your management of OAB (behavioral and medical management approaches still make more sense as first-line therapies). I chose to review this article because it's another "arrow" in your "quiver" of OAB treatments. PTNS isn't for every patient with OAB, but it appears to have benefit for women who either fail medical therapy or have need for improvement beyond what the various medications offer. I don't know about you, but I really get a kick when a patient who is initially a tough diagnostic and/or therapeutic challenge tells me that she didn't think she'd ever feel this good again or that she had given up hope until we found an effective treatment for her symptoms.
(This kind of reminds me of why we all went to medical school in the first place)
In a retrospective chart review at a single university urogynecology practice between 2000 and 2009, the authors identified 197 patients who underwent posterior tibial nerve stimulation (PTNS) after failing medical therapy for overactive bladder (OAB) with anticholinergic medication.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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