Treatments for refractory overactive bladder and urge incontinence

In addition to Botox, patients with overactive bladder and urge incontinence who have failed on medication can choose from two procedures that work by modulating nerve activity.

In addition to Botox, patients with overactive bladder and urge incontinence who have failed to improve on medication can choose from two procedures that work by modulating nerve activity: sacral neuromodulation and percutaneous nerve stimulation.

Both treat overactive bladder and urinary urgency, with or without incontinence. Patients can pick the treatment that best fits their preferences and risk profile.

Sacral neuromodulation

Sacral neuromodulation is a two-stage procedural intervention designed to stimulate the sacral nerve by placing an electrode through the S3 foramen, where the nerves travel from the spinal cord to the bladder.

The first stage is to place a temporary, external device using an external battery and some small incisions on the buttock for the lead. The procedure can be done in the office or the operating room.

In the weeks beforehand, the patient completes a bladder diary. With the temporary device in place, they keep a diary to see if they experience an improvement in symptoms of more than 50%. If so, they can move to implantation of the permanent device, which is done in the operating room.

With the permanent device, a battery is placed under the skin of the buttocks. The options are a battery with a 10-year life or a rechargeable battery with a 15-year life. Batteries can be replaced in a 30-minute operating room procedure.

The company that makes the device has made improvements both to the technology and the device itself. The device now can be adjusted using a cellphone app for the best symptom response. The battery life has been improved, and the battery and electrode are also now MRI compatible, which has been a big concern. Changes also have been made to keep the electrode from slipping under the skin.

Patients are generally very satisfied with sacral neuromodulation. Unless they are thin, patients usually can’t even feel the implanted battery. Potential side effects are pain and infection at the lead site, which are uncommon and require the lead and battery to be replaced.

Sacral neuromodulation is not limited to treating overactive bladder. The procedure can be used to treat urinary retention — difficulty voiding the bladder — allowing patients to void normally and eliminating the need to self-catheterize.

In addition, sacral neuromodulation treats fecal incontinence, eliminating the need for leakage pads. Complicated surgery is the only other option for patients whose symptoms have not been addressed by behavioral or medical management.

Patients are extremely happy when they learn there is a single procedure that can treat both urinary urgency and urinary and fecal incontinence.

Percutaneous nerve stimulation

A second treatment for overactive bladder through nerve modulation is percutaneous nerve stimulation. This is an in-office treatment stimulating the tibial nerve using an acupuncture-like needle. This treatment requires weekly, 30-minute treatments for 12 weeks and then monthly treatments after that. The amount of electrical stimulation can be adjusted for the best results.

Percutaneous nerve stimulation is highly effective but asks a lot of the patient. The only potential side effect is injection site irritation. Because it is noninvasive, the treatment is good for patients who are too sick to have the sacral nerve modulation procedure or who have a lower tolerance for risk.

Patients who have tried medications and found them ineffective or experience significant side effects now have options that are safe and effective for their overactive bladder symptoms. Typically, these are covered by insurance.

It’s hard to overstate how much these treatments change the lives of my patients. Before treatment, many told me they didn’t want to leave their homes — either because of their symptoms or because they were afraid that they smelled of urine or stool. Afterward, they no longer feel the need to self-isolate. These procedures really have a huge impact on their lives.

Andrew D. Doering, M.D.

Dr. Doering is a urogynecologist at Norton Urogynecology Center, seeing patients in St. Matthews and in Clarksville, Indiana. Dr. Doering completed a fellowship in female pelvic medicine and reconstructive surgery at Indiana University School of Medicine, Indianapolis, and his residency in obstetrics and gynecology at The Ohio State University College of Medicine, Columbus. He received his doctor of medicine from the University of Kentucky, Lexington.

Read Dr. Doering’s full profile

Dr. Doering’s recently published research


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