Treating OAB With 3rd-Line Therapy
This past week I had a patient who finished her 12 weeks of the initial treatment protocol with PTNS after she had her SNS device removed.
This patient originally opted for SNS (Sacral Nerve Stimulation) over PTNS because she felt that SNS was the quickest way to get the satisfaction that was not achieved with behavioral management combined with medications. At the time she had no chronic back pain or pathology that might indicate she would need an MRI in the near future. She was 50-years-old and worked for a packaging company. I counseled her regarding the possibility of injury that would require an MRI in the future as she planned to work another 15 years. She was convinced that she was healthy and used excellent body mechanics. She also took safety classes annually that reviewed proper body mechanics and she was generally physically fit. She convinced me she was making the right decision.
The Downside of SNS
The patient did well with the initial placement of her SNS leads. After placement of her SNS, she was in the clinic a couple of times for reprogramming over the next two years. All seemed to be going well. The next time I saw her she was in tears. She had a terrible back injury at work and needed an MRI. Hence, the SNS needed to be removed. She was concerned she might have chronic problems and need additional MRIs of her back. She was also concerned about how to manage her bladder problems without SNS.
It is important to note is that this is a patient with very severe disease. When urodynamics was done prior to insertion of SNS, she had detrusor instability at 63 ml with total bladder emptying. After insertion of SNS, she did better, but still had some leakage. However, her bladder capacity was increased to 221 ml before she had an unstable event and her urgency was much less. We discussed her intake of bladder irritants and how that was obviously affecting her bladder. We also revisited her toileting schedules and her morning coffee. Decreasing her caffeine intake and toileting prior to urge helped her maintain normal bladder voiding levels with no leaking. She was ecstatic that she was doing well. It did come with some difficult choices. She no longer drank 3 cups of caffeinated coffee and decreased to one cup of decaffeinated coffee a day. She voided with initial urge after that coffee and then every two hours throughout the day with or without urge.
A Patient's Choice
We revisited PTNS as an option for her. We started PTNS and she subsequently had her SNS removed. She was quite surprised that her bladder control maintained stable along with some additional improvement during this process. She was voiding eight times per day, slept through the night and had no leaking episodes. These are great outcomes.
She was quite surprised that PTNS had similar effects on her bladder as the SNS. We revisited behavioral interventions because she did not feel that when they were initially introduced that there was any actual change in her symptoms. As a provider I feel it is important to be relentless when it comes to managing behavioral changes in our patients that we know directly affect bladder function. The patient is now continent and voids as often as someone without OAB. She realizes that her bladder problem is chronic. She will be receiving her ongoing PTNS therapy as needed.
Patients have to make difficult choices sometimes, but we need to keep it in perspective. These are their choices, not ours. We just need to be the catalyst to make it happen.
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 only. Urgent is a registered trademark of Cogentix Medical © 2015 Cogentix Medical. All rights reserved.