What is Percutaneous Tibial Nerve Stimulation and its Benefits?

Percutaneous tibial nerve stimulation is one of the advanced treatment modalities of care that are widely used to manage moderate cases of incontinence. It is usually used after the failure of Kegel exercise, behaviour modification and medical management. The classic benefit of opting for percutaneous tibial nerve stimulation (also abbreviated as PTNS) is to reduce the risk of complications by more aggressive procedures like surgical intervention.

How is Percutaneous Tibial Nerve Stimulation performed?

The working principle of PTNS is to apply indirect electrical stimulation to the nerves that are responsible for sensory and motor control of pelvic floor muscles and bladder function.

During percutaneous tibial nerve stimulation, the foot of the patient is comfortably supported and stabilized with the help of a stand. The technician than apply a small needle electrode at the tibial nerve (towards the medial aspect of the ankle) as part of the procedure. This electrode is then connected to a device called Urgent PC stimulator which is designed to create and transmit mild electrical pulses to the tibial nerve. These impulses then travel all the way to the sacral nerve plexus, which is a group of nerves located at the base of the spine to control the normal functioning of the bladder.

Stimulation of tibial nerves via neuromodulation i.e. gentle electrical impulses can assist in modifying the activity of the bladder. Since this change in bladder activity occurs on a gradual pace therefore the patient gets a series of 12 weekly treatments; with each session lasting for at least 30 minutes. Once the twelfth treatment is successful completed, the results of the therapy are assessed i.e. how much has it benefited the patient and if the procedure is associated with any immediate or long term complications. To manage the symptoms and sustain the positive effects of therapy, occasional follow-up treatments may also be needed.

What patients are likely to get percutaneous tibial nerve stimulation?

Percutaneous tibial nerve stimulation is a therapeutic procedure that is ideally advised to patients who have been experiencing moderate to severe symptoms due to:

• OAB (overactive bladder)
• Urge incontinence

Increased urinary frequency and urinary urgency

The regulatory agencies outside of the US have also approved this treatment approach and in most parts of the world, this procedure is also used for the management of fecal incontinence. For example, according to the results of a prospective cohort analysis published in Colorectal Diseases journal (2), investigators suggested that percutaneous tibial nerve stimulation is effective at controlling the symptoms of mixed as well as urge fecal incontinence in over 100 subjects (at least in the short term).

Who are not ideal candidates for percutaneous tibial nerve stimulation procedure?

Percutaneous tibial nerve stimulation must be avoided in following scenarios:

• Individuals with implantable defibrillators or pacemakers
• Patients who are planning to get pregnant during the therapy duration or are already pregnant
• Patients who are susceptible to abnormal bleeding
• Patients who have nerve damage that may influence either the pelvic floor muscles or the tibial nerve.

What are the positive aspects of percutaneous tibial nerve stimulation?

Listed below are the pros associated with the percutaneous tibial nerve stimulation therapy for the management of bladder dysfunction:

• Several research and clinical studies have suggested that percutaneous tibial nerve stimulation can improve the functioning of bladder function and urinary activity in more than 60-80% patients.
• Most surgical procedures are associated with high rate of complications and moderate recurrence of disturbing symptoms. Therefore most patients opt for non-surgical modalities of care like percutaneous tibial nerve stimulation.
• It doesn’t require any kind of implants and therefore has no long-term risk of side effects.
• It is considered as a relatively pain-free procedure. The patients who have been treated with PTNS describe it as tingling sensation or a feeling of pulsations in the ankle or foot.
• Patients who respond to PTNS can undergo repeat procedure for optimal improvement of symptoms.

According to a new study reported in the Journal of Urology (3), investigators suggested that the initial cost of percutaneous tibial nerve stimulation is high; yet the initial high cost is offset by the lower cost of follow-up therapy. In fact, after 7-year interval, percutaneous tibial nerve stimulation is the cheapest therapeutic option for the management of

What are the negative effects of percutaneous tibial nerve stimulation?

Listed below are the cons associated with the percutaneous tibial nerve stimulation:

• Patients are bound to a 12 weekly, 30 minute- sessions to achieve significant improvement in the symptomatology.
• Sometimes the results begin to appear after 5 to 6 weeks of initiating the therapy.

The results may vary from individual to individual and with the type/ severity of bladder dysfunction.

Your doctor can take measures to reduce the discomfort during your treatment. You are likely to experience mild redness or discomfort near or at the very site of the nerve stimulation. Nonetheless you won’t experience any major adverse reactions during or after the procedure.

References:

1. Staskin, D. R., Peters, K. M., MacDiarmid, S., Shore, N., & de Groat, W. C. (2012). Percutaneous tibial nerve stimulation: a clinically and cost effective addition to the overactive bladder algorithm of care. Current urology reports, 13(5), 327-334.

2. Hotouras, A., Thaha, M. A., Boyle, D. J., Allison, M. E., Currie, A., Knowles, C. H., & Chan, C. L. H. (2012). Short‐term outcome following percutaneous tibial nerve stimulation for faecal incontinence: a single‐centre prospective study. Colorectal Disease, 14(9), 1101-1105.

3. Jenks, J., Hamid, R., Shah, J., Greenwell, T., Betts, C., Walleser, S., ... & Ockrim, J. (2013, April). Sacral Nerve Stimulation (SNS) for the treatment of idiopathic refractory overactive bladder: Cost-effectiveness compared to optimal medical therapy, botulinum toxin A (BoNT-A) and percutaneous tibial nerve stimulation (PTNS). In JOURNAL OF UROLOGY (Vol. 189, No. 4, pp. E560-E560). 360 PARK AVE SOUTH, NEW YORK, NY 10010-1710 USA: ELSEVIER SCIENCE INC.