Case-Based Review

Diagnosis and Management of Complex Pelvic Floor Disorders in Women

Journal of Clinical Outcomes Management. 2015 June;22(6)

References

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Sacral neuromodulation is typically performed in 2 stages. The first stage is electrode placement and trial period. A percutaneous nerve evaluation is a temporary electrode placement in the office or a permanent lead placement can be performed in the operating room. Correct placement stimulating the S3 nerve root is confirmed by motor and/or sensory testing. If there is an appropriate response, the electrode lead is connected to a temporary external pulse generator and is worn by the patient for a 2–14 day test period. If more than a 50% improvement in symptoms occur, a permanent lead and battery is placed in the operating room. If there is inadequate symptom response, the lead is removed. There are several recognized limitations of the office percutaneous nerve evaluation compared to operating room lead placement, including false-negative responses, possibly due to lead migration [55], incorrect lead placement, or an inadequate test period [56]. However, it is relatively noninvasive and potentially avoids 2 operating room procedures. Regardless of the choice of the initial test period, sacral neuromodulation offers a minimally invasive, long-term treatment option for refractory OAB.

Percutaneous tibial nerve stimulation (PTNS) is an office procedure that stimulates the posterior tibial nerve. This nerve contains L4–S3 fibers that originate from the same spinal segments that innervate the bladder and pelvic floor. In comparision to sacral neuromodulation, percutaneous tibial nerve stimulation is less invasive, less expensive and there is no permanent implant required [57].

Percutaneous tibial nerve stimulation is performed by a physician, nurse, or other advanced practice provider. Patients sit with knees abducted and the leg externally rotated. A 34-gauge needle is inserted 3 cm into the skin 3 fingerbreadths above the medial malleolus. The Urgent PC Neuromodulation System (Uroplasty, Minnetonka, MN) is attached and the amplitude of the stimulation is increased until the large toe curls or the toes fan. Each session lasts 30 minutes and 12 weekly treatments provides the best improvement in patient symptoms [58, 59]. There is a strong carry-over effect and patients generally need re-treatments every 4-6 weeks for 30 minutes.

Percutaneous tibial nerve stimulation has been compared favorably to both anticholinergic and sham treatments. The Overactive Bladder Innovative Therapy Trial (OrBIT) randomized 100 patients to PTNS or tolterodine for 12 weeks. The global response assessment demonstrated a statistically signiﬁcant subjective improvement or cure over baseline in OAB symptoms in 79.5% of the PTNS group vs. 54.8% of the tolterodine group ( P = 0.01)[60]. The SUmiT trial compared the efficacy of PTNS to sham for 12 weeks of therapy [59]. In this multicenter study, subjects were assessed at 13 weeks using the global response assessment for overall bladder symptoms. 55% of PTNS subjects achieved moderately or marked improvement in bladder symptoms compared to 20.9% of sham subjects ( P < 0.001). Voiding diary parameters also improved compared to sham. In an earlier sham controlled trial, 12 patients (71%) in the treatment arm compared to none of the 15 placebo patients, demonstrated more than 50% improvement in diary and quality of life scores [61].