Posted on Apr 6, 2016 7:30:00 AM by Leslie Wooldridge, GNP-BC, CUNP, BCIA-PMD

Choosing 3rd Line Therapy in Overactive Bladder Treatment

Part 5 in the series,OAB Treatment Plans: What Works?

When a patient presents with symptoms of Overactive Bladder, there are a lot of things that come to mind. It is not always as easy as following the AUA/SUFU Guideline for OAB. These guidelines are a great template for finding the right path to take your patients through. However, keep in mind all the little differences patients present with as this may determine successful outcomes. Based on my experience, I have developed a series of blog posts that discuss individualizing treatment plans for the OAB patient.

Three door options

Advanced Treatment for Overactive Bladder

When behavioral management and medications aren’t enough to meet the goals of patients with OAB, it’s time to move on. 

There are three major 3rd line therapies approved for use in patients with OAB.  Percutaneous tibial nerve stimulation (PTNS), sacral modulation (SNM) and onobotulinum toxin A (Botox).  All treatments come with their pros and cons.  In my clinic we have developed a patient education piece that defines 3rd line therapy and outlines the pros and cons of each.  Along with this piece, each company’s patient education materials are provided.  The important thing to remember is that the patient has no idea what any of these treatments are.  As a clinician, it is our prudent responsibility to discuss each option so that our patients understand exactly what they are getting in to.  The ultimate decision must be theirs. 

While reviewing third line therapy with our patients, it is also important to discuss each patient’s co-morbidities.  Not all treatments are right for all patients. Let’s look at some of those co-morbidities as well as other issues to take into consideration and the problems they may present:

PROBLEMS

PTNS

SNM

Botox

Elevated post void residuals (over 200 ml.)

OK to use

Can actually be helpful if not obstructive

Avoid

Implanted pacemaker or defibrillator

Permission from cardiologist for treatment

Permission from cardiologist for treatment

OK to use

Frequent urinary tract infections

OK to use

OK to use

Avoid

Frailty

OK to use as long as patient has intact ankle area

Better to be staged than PNE

Make sure patient has options for post procedure catheterization

Obesity

OK to use

Easier to be staged than PNE depending on agility

Teach patient intermittent catheterization pre-op

Lower extremity neuropathies

Avoid

OK to use

OK to use

Transportation

Requires 12 weekly visits to the clinic

Requires driver for staged procedure or device implant

Requires driver for treatment

Insurance

Pre-authorize

Pre-authorize

Pre-authorize

Poor cognition

Use with caution. May not be able to determine sensory response

Use with caution. May not be able to determine sensory response. Will not be able to use external device unless patient has caregiver.

Use with caution unless patient has caregiver

Wrong diagnosis

Pre-procedure urodynamics helpful if patient history unclear, but not necessary

Pre-procedure urodynamics helpful if patient history unclear, but not necessary

Pre-procedure urodynamics helpful if patient history unclear, but not necessary

Time commitment

Initial weekly visits, then monthly or less often

Battery changed every 5-7 years. May need intermittent programming as well as battery and lead checks

Re-treatment may be needed every 6-12 months

Future diagnostic testing

OK to use

NO MRI below the chin

OK to use

Invasive procedure

NO

YES-device implant

YES-staging

NO-PNE

YES-cystoscopy required for medication injections

Anesthesia

NO

NO-PNE

YES-device implant

Local only

Keep in mind that it is your patient who has to live with the treatments as well as the results of treatment.  And, what if the first thing they choose does not work?  The good news is that there is the possibility of two other treatments as well as combinations of treatments.

Next in the series

Part 6: Using PTNS in Overactive Bladder Treatment
Watch for it next week or subscribe to the blog to ensure you don’t miss any posts in this 7-part series.  

Previous posts

Part 1: Patient History in Overactive Bladder Treatment

Part 2: Physical Exam in Overactive Bladder Treatment

Part 3: Behavioral Management in Overactive Bladder Treatment

Part 4: Medications in Overactive Bladder Treatment

Urgent PC for OAB

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. Urgent is a registered trademark of Cogentix Medical © 2016 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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