Guide to Peripheral Tibial Nerve Stimulation

Peripheral Tibial Nerve Stimulation (PTNS) and Percutaneous Tibial Neuromodulation (PTNM) are two names for the same therapy for Overactive Bladder symptoms. In this therapy, a branch of the nerve to the bladder is stimulated near the ankle. A very small needle is placed under the skin and a very low electrical current signals the nerve. The treatment occurs in a physician’s office and lasts about 30 minutes per session. These sessions have to be repeated to achieve and then maintain improvement with bladder symptoms. An important advantage of PTNS is that it is a minimally-invasive OAB therapy that can be safely used in patients who may be at risk from other therapies.

Patients sit comfortably in a doctor’s office, usually with a leg elevated (to make it easier to access the lower leg). The treatment area is just above and behind the prominent bone (medial malleolus) on the inside of the ankle. Once identified, the area is cleaned with an alcohol wipe and a small needle is inserted a few centimeters under the skin. The needle is very fine and discomfort is minimal (some patients do not even feel the needle). A very low electrical pulse stimulates the tibial nerve, which is a branch of the same nerve system that leads to the bladder. This impulse is often felt as a tingling in the foot and there is often movement of the toes as well. Treatment lasts for 30 minutes. After this, the needle is removed and the patient is able to return to normal activity immediately. There is no need for anesthesia and there are no restrictions for driving or eating before or after the session.

Peripheral Tibial Nerve Stimulation therapy is usually divided into two phases: induction and maintenance. Patients begin with induction treatment consisting of 12 weekly sessions. Most people begin to see improvement by session 6 but the full 12 sessions may be necessary for many patients to see satisfactory improvement. If the twelve induction treatments have been successful in controlling OAB symptoms, treatment then moves to a maintenance phase, which is less frequent. Treatments are typically every 3-4 weeks, though some patients are able to space these out even more. The maintenance treatments have to be maintained to continue to see the positive effects on bladder symptoms.

An important advantage of PTNS is that the risks and side effects are minimal. Some patients experience discomfort from the stimulation but this can usually be fixed by turning down the stimulation setting or moving the needle. Discomfort very rarely prevents treatment from being completed. There can be some slight bleeding at the insertion site but the needle used is so fine that any bleeding quickly stops without intervention. One important note, PTNS is not intended for patients with a pacemaker or defibrillator as there is concern that this type of stimulation may interfere or trigger the cardiac device.

An unfortunate obstacle to PTNS therapy is the need for an office visit to receive the therapy. After completion of the 12-week induction phase (which can be a burden for many patients) the average patient will need to repeat therapy every 4 weeks. For people who do not live near a provider who is experienced with PTNS, this may limit their access to the treatment. There are several solutions to this dilemma under investigation that will hopefully expand access to this therapy in the future.

Numerous studies have looked at the effectiveness of Peripheral Tibial Nerve Stimulation and it is likely that around 70% of patients respond to the therapy. It is helpful to note that many OAB studies define success as 50% improvement in symptoms. This means that someone who urinates 20 times every day would have to see a decrease to 10 times or less to be considered a responder. Someone who averages 4 incontinence episodes per day would be considered successful if they saw only 2 episodes per day with treatment. Some, but not all, patients continue to see the same improvement in symptoms over long periods of time, with studies up to 3 years.

PTNS has been compared with medications for control of bladder symptoms and found to be similarly effective. An advantage of PTNS over medications is that there are fewer side effects.