Posted on Sep 3, 2015 11:28:00 AM by Leslie Wooldridge, GNP-BC, CUNP, BCIA-PMD

Urgent PC Technique: What Really Matters?

Patient reading while undergoing PTNS

I get a lot of questions regarding Urgent PC technique. Some say they do things differently than what the instructions might say.  Here are some thoughts on where you can alter technique and what is most important.

QUESTION: Do I have to insert the needle at a 60° angle, as instructed in the Urgent® PC Instructions for Use?

ANSWER: Based on my experience, I have found this is not necessarily the case. As you know, the goal is to have the needle closest to the nerve without hitting the nerve. To this end, it is very critical that you insert the needle caudally. For the most part, 60° is a good angle to get the needle in the approximate location.  A couple points:   

  • Some ankles are very large and putting the needle in straighter, maybe even up to 90° can make some sense.
  • NEVER insert less than 60°.  You may never get a proper response because the needle will not get close enough to the nerve.  The needle will be too superficial and the response will be at the needle only.

As you get more experience, you will have a better sense about what ankles can tolerate an angle greater than 60°.  I generally start at 60° but a greater angle is sometimes OK if you get the proper responses.

QUESTION: What response is adequate? Is a toe flex enough?

ANSWER: I will always try to get heel foot sensation along with a toe flex. You can be fooled by a toe flex only, as the sensation at the needle site can be startling at times if it is too strong and can cause the toes to flex.  This is not a neural response.  It is a response to pain.

When just toes flex, I will ask if there is a heel/foot feeling of sensation.  If yes, I am good with that and will push the limit with increasing stimulation all the way to toleration.  The patient should NEVER have a painful feeling.

Another thing you can do is to ask the patient to flex his/her toes and see how they do it. Try it yourself. There are certain toe flexion responses that cannot be performed on command.  Look for those, i.e. fanning of the toes, flexion of one toe other than the big toe and/or a combo of flexion and fanning.

QUESTION: How fast should I move through the stimulation levels?

ANSWER: When you turn the Urgent PC device on, push “test” until you see 0.  Look at the toes.  Wait for a response. If no response you may push arrow up to the next level.  Wait again for a response.  When I get to about 3 or 4, I will start asking the patient if he/she is feeling anything. If they do, whether it is at the needle or the foot, I will increase stimulation as far as tolerated, but not painful, to see if I can get the proper response.  Arrow down if the sensation is too strong. Always ask the patient if the stimulation is tolerable.  If yes, try up until they are feeling their max response.  If no, arrow down one.  I will always try to get both responses, heel, foot and toe flexion.  A combination of any of these is adequate. 

If your patient is not getting good results, always look at technique.  Are you getting the right response?  Is the stimulation as high as tolerated?  Don’t be afraid to change the needle.  That is why two needles come with each lead set.  Be patient and take your time.  Most times your technique will be right on.  Sometimes it seems like nothing works.  Go through the steps in your head and start over when necessary.  There is nothing better than hearing your patient say, “WOW! I have never had a response like that before!”

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This blog post reflects the opinions and experience of Leslie Wooldridge, a long-standing user of the Urgent PC Neuromodulation System, and was produced under a paid consulting agreement with Cogentix Medical.

Urgent PC is indicated for the treatment of Overactive Bladder and associated symptoms of urinary urgency, urinary frequency and urge incontinence. Treatment with Urgent PC is contraindicated for patients with pacemakers or implantable defibrillators, patients prone to excessive bleeding, patients with nerve damage that could impact either percutaneous tibial nerve or pelvic floor function or patients who are pregnant or planning to become pregnant during the duration of the treatment. Most patients don't experience side-effects. If side-effects occur, they are typically temporary and include mild pain and skin inflammation at or near the stimulation site. Caution: Federal law (USA) restricts this device to sale by or on the order of a physician. For complete instructions for use, storage, warnings, indications, contraindications, precautions, adverse reactions and disclaimer of warranties, please refer to the insert accompanying each product or online at www.cogentixmedical.com. Models are for illustrative purposes. Urgent is a registered trademark of Cogentix Medical © 2015 Cogentix Medical. All rights reserved. 

Leslie Wooldridge, GNP-BC, CUNP, BCIA-PMD
Leslie Saltzstein Wooldridge, GNP-BC, CUNP, BCIA-PMD, is Director of the Adult Bladder Control Center, Mercy Health Partners, Muskegon, Michigan USA. Ms. Wooldridge received a Master of Science degree in nursing administration, critical care nursing and postgraduate certification as a Geriatric Nurse Practitioner from Marquette University, Milwaukee, Wisconsin. In 2015, she was honored with the Women’s Health Foundation Activist Award. She is also the recipient of the 2009 National Association for Continence Rodney J. Appell Continence Champion Award. Ms. Wooldridge has published in multiple refereed journals. She authored the Genitourinary chapter in The Nurse Practitioner in Long Term Care: Guidelines for Clinical Practice (2007). She has lectured throughout the United States on geriatrics, urology and clinical practice.
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