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Summer 2008 And the Ankle Bone’s Connected to the…Bladder?
Overactive bladder, often associated with urinary urgency, urinary frequency, nocturia, and urinary incontinence, can be very disturbing and distressing to patients. Conventional therapies, which include anticholinergic medication, biofeedback, implantable (central) neurostimulation, and behavioral therapy, have limitations. Side effects frequently limit the efficacy of anticholinergic medication, while the insertion of a vaginal probe, as needed for biofeedback, makes this treatment uncomfortable for many patients. Many patients are also unwilling to undergo the two surgical procedures required for implanting a central nervous system neurostimulator (Interstim). Peripheral neuromodulation is an office–based procedure, which has proven to help many patients with overactive bladder. Percutaneous Tibial Nerve Stimulation (PTNS) consists of the insertion of a needle behind the ankle, above the medial malleolus into the posterior tibial nerve, followed by the application of electrical stimulation. The therapy is based on the common nerve roots (S2–S3) shared by the posterior tibial nerve, which runs behind the ankle, and the bladder. Stimulation of the posterior tibial nerve has been shown to improve voiding function and reduce urgency and urge incontinence. Patients often experience sensory and motor responses (i.e., a tickling sensation and plantar flexion or fanning of all toes). This therapy is different from stimulated acupuncture, which is not based upon neural pathways but upon theories of energy flow throughout the body. Treatment usually involves 30–minute sessions given weekly for 10 to 12 weeks. PTNS was developed as a less–invasive treatment alternative to sacral root neuromodulation, which requires implantation of a permanent device. Yale Urogynecology and Reproductive Pelvic Surgery is the first practice in New Haven County to utilize this therapy. We have been using PTNS for over one year for patients with urinary urgency, urinary frequency, and urge incontinence. Generally, patients who choose not to take medication, who have not responded to medication, or in whom medication is contraindicated have been offered this therapy. Approximately 80% of treated patients have responded with improvement in symptoms and have been happy with the results. Follow–up care is underway to determine how long improvement persists once therapy is discontinued. PTNS has also been used for treating patients with interstitial cystitis (IC), a painful bladder condition associated with urinary urgency and frequency, which is often resistant to medication and physical therapy. In one study, done in Beijing, there were significant improvements in symptomatology after treatment with PTNS. Nighttime bladder volume, Interstitial Cystitis Problem Index score, O’Leary/Sant Interstitial Cystitis Symptom Index score, and health status scores all showed improvement.
“I think PTNS is simple and easy to use with no complications,” Dr. Jimao Zhao from Beijing Friendship Hospital in the People’s Republic of China told Reuters Health. “Our experiences have shown that it can improve some symptoms in patients with interstitial cystitis.” Given its low complication rate and ease of use, PTNS may be considered for patients with IC who are unhappy with their response to more conventional therapies. Finally, we now know that many patients with chronic pelvic pain, especially those with endometriosis, also have urinary symptoms, and as many as 30% of these will be diagnosed with Interstitial Cystitis. PTNS may also be helpful in those patients with chronic pelvic pain who fall into this category. Office cystoscopy can often identify these patients, allowing for a more comprehensive treatment program for their chronic pelvic pain. The Yale Urogynecology and Pelvic Reconstructive Surgery practice, located in the Yale Physicians’ Building at 800 Howard Ave. in New Haven, has been designated a Center of Excellence for the evaluation and management of Interstitial Cystitis/Painful Bladder Syndrome. |
