According to the AUA/SUFU guideline, Diagnosis and Treatment of Overactive Bladder (Non-Neurogenic) in Adults, PTNS is considered a 3rd line treatment for patients who have failed behavioral therapy and at least one antimuscarinic drug due to lack of efficacy. But as a clinician, there are other times when percutaneous tibial nerve stimulation (PTNS) is indicated.
I see patients all the time who may have gotten some benefit from behavioral but persist with bothersome urgency, or patients who were unable to tolerate adverse drug effects of OAB antimuscarinic medication. I also see patients where I feel OAB medication may be contraindicated. That adds up to lots of patients who may benefit from PTNS treatment with Urgent® PC. So, it is important that clinicians develop a patient-centered approach to preparing the appropriate patient for PTNS treatment.
- First, you need to explain why you feel that PTNS treatment with Urgent PC is the next best option for the patient. After failing behavioral and drug therapy, patients are usually discouraged and in some cases desperate for something that can help them. So clinicians who routinely treat patients with OAB have to have the option of PTNS treatment available in their office. Of the all the 3rd-line treatments for OAB, PTNS is the least invasive and is easy to administer.
- Second, identify the patient’s most bothersome symptom and determine if PTNS can be effective. Achieving continence in a patient who has severe mixed incontinence may not be possible.
- Third, you should have a discussion with the patient about realistic expectations. An example of an unrealistic expectation would be a patient who is 75, has hypertension, takes a diuretic, and expects to be able to void no more than 6 times a day and to not awaken at night with the need to urinate. That may not be achievable as diuresis from the diuretic is probably contributing to day and nighttime frequency.
- Fourth, you need to take time and review the treatment with the patient, discussing the actual procedure, alleviating any fears of the needle insertion, and setting up realistic expectations. I have found that it may take as many as 6 visits before patients see an improvement in symptoms. So I discuss this at the first visit.
- Fifth, improvement may be intermittent which means that if one of the patient’s goal is to decrease urgency and develop more “control” of urination, then they may start to see this improvement after 6 PTNS treatment but not consistently every day until the patient has received all 12 treatments. So I try to prepare patients for these more realistic changes prior to starting the 12 treatments. I think this improves patient’s compliance with PTNS.
There is a great deal of research showing the effectiveness of PTNS but what is lacking is use in the clinical setting. I would be interested in comments to this blog on what you are doing in your practice to prepare your patient for PTNS.
This blog post reflects the opinions and experience of Diane Newman, 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 only. Urgent is a registered trademark of Cogentix Medical © 2015 Cogentix Medical. All rights reserved.