Bladder Stimulator Treatment Indications
Bladder stimulators (sacral neuromodulation and posterior tibial nerve stimulation) are primarily used to treat overactive bladder (OAB) with urgency, frequency, and urgency incontinence, as well as neurogenic lower urinary tract dysfunction (NLUTD) in select patients.
Primary Indication: Overactive Bladder (Non-Neurogenic)
Sacral Neuromodulation (SNS)
- SNS is a third-line treatment for non-neurogenic OAB when first-line behavioral therapies and second-line pharmacologic management have failed 1
- Patients must have moderate to severe symptoms and be thoroughly counseled about the procedure 1
- This is a standard recommendation for carefully-selected patients who desire further treatment after inadequate response to medications 1
Posterior Tibial Nerve Stimulation (PTNS)
- PTNS is also a third-line treatment option for non-neurogenic OAB 1
- Patients must be willing and able to make frequent office visits, as this therapy requires regular sessions 1
- PTNS is offered as an alternative to SNS for patients with urgency, frequency, and/or urgency incontinence 1
Secondary Indication: Neurogenic Lower Urinary Tract Dysfunction
PTNS for Neurogenic Bladder
- PTNS may be offered to select spontaneous voiding NLUTD patients with urgency, frequency, and/or urgency incontinence 1
- This benefit has been primarily demonstrated in patients with multiple sclerosis (MS), Parkinson's disease (PD), and cerebrovascular accident (CVA) who have OAB symptoms and continue to void volitionally 1
- The key requirement is that bladder problems are mainly isolated to storage symptoms in patients who still spontaneously void 1
SNS for Neurogenic Bladder
- SNS (specifically the Finetech Brindley Bladder System) is FDA-approved for improving bladder function in patients with spinal cord injury (SCI) 2
- This device helps avoid the need for clean intermittent catheterization in SCI patients with neurogenic bladder 2, 3
- The traditional FDA-approved implantation combines SNS with posterior rhizotomy to reduce reflex bladder contractions 2
Treatment Algorithm for OAB
The hierarchical approach follows this sequence 1:
- First-line: Behavioral therapies (bladder training, fluid management, pelvic floor exercises) 1
- Second-line: Pharmacologic management with antimuscarinics or beta-3 adrenoceptor agonists 1
- Third-line: When treatment goals are not met after appropriate duration of first and second-line therapies, offer either:
Critical Patient Selection Criteria
For Non-Neurogenic OAB
- Patient must have failed or had inadequate response to behavioral and pharmacologic therapies 1
- Patient must desire further treatment and be willing to engage in the treatment process 1
- Moderate to severe symptoms warrant consideration 1
For Neurogenic Bladder (PTNS)
- Patient must be able to spontaneously void 1
- Symptoms should be predominantly storage-related (urgency, frequency, urgency incontinence) 1
- Most evidence supports use in MS, PD, and CVA patients 1
For Neurogenic Bladder (SNS)
- Primarily indicated for SCI patients with complete paraplegia and neurogenic bladder 2
- Patient should have bladder dysfunction not satisfactorily controlled with intermittent catheterization 2
- The device provides an alternative to lifelong catheterization 2, 3
Important Caveats
Do not confuse bladder stimulators with botulinum toxin therapy: While both are third-line treatments for OAB, botulinum toxin requires patients to be willing to perform self-catheterization if retention occurs 1, 4, whereas SNS and PTNS do not carry this same requirement.
PTNS requires ongoing commitment: Unlike SNS which is implanted, PTNS requires frequent office visits for repeated stimulation sessions 1, making patient compliance and accessibility critical factors.
Limited evidence in some neurogenic conditions: While PTNS shows benefit in MS, PD, and CVA patients with NLUTD, the evidence is less robust than for non-neurogenic OAB 1.