In case you don't know about Percutaneous Tibial Nerve Stimulation

[MakeItGoAway]

In case you don't know about Percutaneous Tibial Nerve Stimulation:

https://bmcurol.biomedcentral.com/ar...94-020-00629-y

[KoKo]

Hey MakeItGoAway!

Very interesting! Thank you for the info.

Looks like a treatment with the least amount of risks / side effects (so far).

I didn't realize that Botox could cause UTI's and bladder retention.

And of course the various drugs have side effects of their own.

In PTNS, a solid needle is inserted into the back of the leg (calf area?) in order to stimulate the nerve.

Although the studies need to be done for a longer term to really assess if there may be any side effects.

Excerpt from the article:

"Each intervention can have significant quality of life implications. For example, second line pharmacotherapy with anticholinergic is often poorly tolerated because it can exacerbate symptoms of dry mouth, constipation and central nervous system side effects like confusion [8]. Likewise, the addition of intermittent catheterization can add complexity to the patient’s lifestyle with unclear impact on decreasing LUTS [11]. In regards to third line therapy, intradetrusor onabotulinumtoxin (Botox) can be effective at controlling symptoms, but it requires cystoscopy to administer, the treatment needs to be repeated every 6–12 months, and each administration carries a risk of urinary tract infection and urinary retention [12].

Neuromodulation, another third line therapy, includes both sacral neuromodulation and posterior tibial nerve stimulation. Sacral neuromodulation involves 1 or 2 surgeries for placement of a neuromodulation lead and an implantable pulse generator to stimulate the S3 nerve root. Limited data suggest sacral neuromodulation may be effective for MS related LUTS, however the sacral neuromodulation leads are not MRI compatible [8, 13, 14]. Since many patients with MS require frequent MRI for surveillance, this poses a barrier for use of current implantable sacral neuromodulation technology. In these patients, percutaneous posterior tibial nerve stimulation (PTNS) offers a minimally invasive alternative to relieve bladder symptoms via similar pathways as sacral neuromodulation.

Posterior tibial nerve stimulation, involves placement of a solid stainless-steel needle into the posterior tibial nerve and uses this to conduct a fixed electrical pulse through the nerve. The posterior tibial nerve derives from the L4-S3 nerve roots, neuromodulation of this nerve has been shown to improve overactive bladder symptoms [15]. The office-based therapy is performed weekly for 12 weeks during 30-min sessions; patients who have improvement in symptoms can proceed to maintenance treatments at regularly scheduled intervals.

Only seven clinical studies have been published regarding the use of PTNS in patients with MS and refractory LUTS [16,17,18,19,20,21,22]. (Table 1) Of these studies, four represent prospective case series evaluating the efficacy of PTNS for LUTS in MS, with a total of 131 patients [18,19,20, 22]. These studies reported significant improvement in LUTS with overall the rate of improvement (defined as greater than 50% improvement in symptoms) between 33 and 89% (Table 1). Table 1 Literature review of Posterior Tibial Nerve Stimulation in Multiple Sclerosis Full size table

Despite these findings, the studies were limited by their short term follow up (range 3–12 months), strict inclusion criteria, and lack of important quality of life outcomes. Outcomes beyond 12 months and the impact of standard maintenance therapy have only been studied in one prior study [20]. Moreover, there is limited research on the effects of PTNS on related pelvic organ dysfunction such as bowel and sexual function among patients with MS. [23, 24] As PTNS requires significant investment on the part of patients and clinicians, further studies generating more robust evidence regarding the long term impact of this therapy are warranted. Furthermore, we believe it is important to follow PTNS treatment outcomes longitudinally to determine if it is effective in a progressive disease such as MS. Previous published PTNS studies did not address how efficacy could be affected by the type of MS, disability status or whether the efficacy could be maintained long term in the setting of a progressive disease."

[Kimba22]

PTNS, a solid needle is inserted into the back of the leg (calf area?) in order to stimulate the nerve

The needle is inserted above the inner ankle, near the tibial nerve. The needle is connected to a small stimulator that controls the impulses. A ground pad is adhered to a clean, smooth area of skin within reach of the needle insertion site. Typical areas include the instep and heel of foot. The impulses travel to the tibial nerve and then to the sacral nerve, which controls bladder control and function.

PTNS is given once a week for 12 consecutive weeks. Each session is 30 minutes. It usually takes 5-7 weeks for patients to see a change in bladder control. A patient should have all 12 initial treatments before evaluating if this is the appropriate and effective treatment. For patients who respond to treatment, the time between therapy sessions may be slowly increased after the initial 12 therapy sessions to once a month.

There are two different devices available. Laborie Medical Technologies has the Urgent PC neuromodulation system, while Medtronic has the NURO system. The NURO neuromodulation generator is much smaller and is attached to the ground pad on the foot, while the Urgent PC generator is larger and is not.

Sacral neuromodulation involves 1 or 2 surgeries for placement of a neuromodulation lead and an implantable pulse generator to stimulate the S3 nerve root. Limited data suggest sacral neuromodulation may be effective for MS related LUTS, however the sacral neuromodulation leads are not MRI compatible. Since many patients with MS require frequent MRI for surveillance, this poses a barrier for use of current implantable sacral neuromodulation technology.

In 2012, Medtronic obtained Food and Drug Administration (FDA) approval for allowing 1.5 Tesla (T) MRI head scans. In September 2019, the Axonics System (Axonics) received FDA approval for 1.5 T full‐body MR Conditional labeling and then 3 T full‐body MR Conditional labeling in July 2020. In August 2020, Medtronic received 1.5 and 3 T full‐body MR Conditional labeling from the FDA for their new SNM systems (InterStim II and Micro devices with SureScanTM leads).

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9290516/

[KoKo]

Great info, Kimba!

Thank you for helping to make this stuff a little more clearer and easier to understand.