Patients referred for advanced therapies for overactive bladder can expect either Botox injections, percutaneous tibial nerve stimulation or sacral neuromodulation, according to a specialist with the Norton Urogynecology Center.

OnabotulinumtoxinA, or Botox, is an office-based therapy, performed under local anesthetic.

“A small camera is inserted in the bladder and s small needle passes through that camera and to inject about 20 different places in the bladder,” said Marjorie L. Pilkinton, M.D., a urogynecologist with Norton Urogynecology Center. “Botox works in the bladder exactly like it works in the forehead. It partially paralyzes the muscle to where the sudden urge to urinate lessens and more normal urges return.”

Self-catheterization may be necessary for about 1 in 10 to 20 patients

“The patients who are going to get Botox must be willing and able to perform self-catheterization, if necessary,” Dr. Pilkinton said. “Many times, retention of urine is asymptomatic, but even in asymptomatic patients, the risk of urinary tract infection increases.”

Self-catheterization may be necessary for three weeks to a month until the Botox wears off a bit, according to Dr. Pilkinton.

The therapy itself wears off after four to 12 months, with a median of nine months, and can be repeated to achieve the same response to treatment.

Botox is effective in about three-fourths of women, according to Dr. Pilkinton.

Additional options for third-line therapy

The other options for third-line therapy for overactive bladder are either tibial nerve stimulation or sacral neuromodulation.

“When I talk to patients about these two, I typically say these are sort of bladder pacemakers,” Dr. Pilkinton said. “These sound like science fiction to patients, but these things work, and they’re tolerated well and are well-covered by insurance companies.”

Tibial nerve stimulation is a 30-minute, office-based therapy. An acupuncture needle is placed behind the ankle and connected to a stimulator, which sends a signal up the posterior tibial nerve. That signal communicates with the nerves of the bladder.

“We think the way this works is through the interneuronal pooling at the spinal level,” Dr. Pilkinton said. “We stimulate the tibial nerve. Some of those neurotransmitters spill over at the spinal level, and they communicate with the nerves to the bladder.”

Tibial nerve stimulation needs to be repeated weekly for 12 weeks and then monthly after that to maintain urinary improvement.

Approximately 60% of patients feel better after tibial nerve stimulation.

Sacral neuromodulation is an implanted device. A small lead is placed alongside the sacral nerves.

Before the complete implant procedure is done, patients can wear a generator outside the skin for a week to see if it’s effective. If it improves symptoms by 50% or more, then patients can choose the implant.

As with Botox, about three-fourths of patients show improvement.

“The other added benefit is in patients with fecal incontinence. The stimulator can improve fecal incontinence control as well,” Dr. Pilkinton said.