Advanced therapies for overactive bladder

Patients referred for advanced therapies for overactive bladder can expect either Botox injections, percutaneous tibial nerve stimulation or sacral neuromodulation, according to J. Ryan Stewart, D.O., a urogynecologist with Norton Urogynecology Center.

Patients referred for advanced therapies for overactive bladder can expect either Botox injections, percutaneous tibial nerve stimulation or sacral neuromodulation, according to J. Ryan Stewart, D.O., a urogynecologist with Norton Urogynecology Center.

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

“It typically doesn’t hurt. I put a small camera in the bladder and pass a small needle through that camera and inject about 20 different places in the bladder,” Dr. Stewart said. “Botox works in the bladder exactly like it works in the forehead. It paralyzes the muscle.”

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

Dr. Stewart starts with 100 units initially, which is too much — at least temporarily — for 10% to 15% of patients, who have high post-void residuals.

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

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

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

Botox is effective in about two-thirds of women, according to Dr. Stewart.

“Botox is a very good treatment, but you’ve got to choose the right patient,” he added.

Additional options for third-line therapy

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

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

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.

“I tell my patients it’s the only procedure I know that you can try before you buy,” Dr. Stewart said.

Like the other two treatments, about 60% of patients show improvements, while 30% or more have a cure.

“The other added benefit is in women with fecal incontinence. There have been some reports that fecal incontinence can be improved with this as well,” Dr. Stewart said.


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