Understanding Tibial Nerve Stimulation for Overactive Bladder

If you've tried lifestyle changes and medications for overactive bladder, but you're still dealing with urgency, frequency, or leaks, you're not out of options. In this episode, I break down tibial nerve stimulation, a lesser-known but powerful treatment for overactive bladder that's often overlooked in early care plans.

I discuss what neuromodulation means in pelvic health, and how it works, why the tibial nerve (yes, the one near your ankle!) plays a key role in calming bladder activity, the differences between transcutaneous, percutaneous, and implant-based tibial nerve stimulation, what to expect from the procedure, how often it's done, and why so many women tolerate it well, and the best part? Minimal side effects and multiple delivery methods make this a versatile, low-risk option for many women, especially if medications haven't worked.

For more information on this subject, check out:
S2E12: Finding Freedom with Sacral Nerve Stimulation
S2E35:Innovations in Overactive Bladder Solutions with Isaac Oppenheim
Livezida.com
Avation.com

Timeline

00:30 Introduction to Tibial Nerve Stimulation 
01:14 Understanding Neuromodulation 
02:05 Causes and Symptoms of Overactive Bladder 
03:13 Sacral Nerve Stimulation Overview
04:21 Focusing on Tibial Nerve Stimulation 
06:18 Transcutaneous Tibial Nerve Stimulation 
11:47 Percutaneous Tibial Nerve Stimulation 
16:20 Conclusion and Future Episodes

Transcript

 Hi there. Today I wanted to talk to you about tibial nerve stimulation. Tibial nerve stimulation is a treatment for overactive bladder. It's not a first line treatment. First, we wanna make sure that you understand all the behavioral things that you can, that you are aware of, bladder irritants, that you have a strong pelvic floor.

We usually try medications before trying tibial nerve stimulation, but tibial nerve stimulation is the newest way that we have to treat overactive bladder. And there are a couple of different ways that we can do it. So let me just take a step back. Tibial nerve stimulation is a form of neuromodulation, and I decided to do this episode after interviewing another physician who kept saying neuromodulation.

And I just thought that that was such a confusing term. So neuromodulation is defined as a therapeutic approach that alters nerve activity to achieve desired effects. Often including electrical stimulation of the nerve or drug delivery targeted to a specific neurologic site. In urogynecology, we use neuromodulation to treat overactive bladder, urinary retention and fecal incontinence.

But today I'm just focusing on overactive bladder. So overactive bladder is caused by the involuntary contraction of the bladder. When your bladder contracts, it empties, your bladder should only contract when your brain is telling your bladder that it is a reasonable and safe time to empty. And with overactive bladder, you start getting contractions at times that are not optimal and times where you don't want your bladder to be contracting.

So this is often due to a nerve dysfunction. Something is disrupted in the brain bladder connection. It can be neurological. So we see this with different neurological diseases like multiple sclerosis, but it's often idiopathic, meaning that we don't really know why it is happening. Your bladder is just contracting, your bladder is responding to other signals, and we think this is because of increased nerve activity.

So if we can alter or change the neurologic or nerve signals to the bladder, then you can change the symptoms. When we talk about neuromodulation in urogynecology, there are two different nerves that we can stimulate. One is your third sacral nerve, and this is in your back. And we do this with sacral nerve stimulation.

We stimulate the. Third sacral nerve using a mild electrical impulse, and this changes the communication between the brain and the sacral nerves, which control bladder and bowel function. This type of stimulation requires a surgery where we place what's almost like a pacemaker for the bladder. We usually do a trial to see how it works, and then we go ahead and we implant it.

There are two companies that offer this technology, Boston Scientific and Medtronic, and I've done episodes on sacral nerve stimulation in the past. If you're interested in learning more about sacral nerve stimulation, I would tell you to go back from season two, episode 12, where I talk about sacral nerve stimulation.

But the other type of neuromodulation we can do is stimulating the tibial nerve, and I'm gonna focus on the tibial nerve for the rest of this episode. This is the newest technology, like I said, and there are three different ways that you can stimulate the tibial nerve. So you can stimulate the tibial nerve transcutaneous, and this means that you are stimulating it with something on the skin, like a patch or a device that is placed directly on the skin.

The second way you can stimulate the tibial nerve. Percutaneously, and this means that you're putting something through the skin like a needle. And then the last way you can stimulate the tibial nerve is with an implant. And when we do an implant, this is a surgery. Sometimes it's done in a surgery center, sometimes it can be done in the office.

Where you're placing a device under the skin, and there are different ways that you can do this. There are different technologies that will stimulate the tibial nerve. So with the eco, which is an implant for the tibial nerve stimulation, you place a battery under the skin and this stimulates the nerve at a regular interval and you don't have to do anything.

With the Revy, you place a lead underneath the skin and then you have to wear a device over the lead at a regular interval. So sometimes weekly, sometimes daily, depending on what you wanna do, that will stimulate the nerve. So that one requires a little bit more effort from you. The next couple of podcasts that I do are gonna focus on the different implants.

So for today, I am going to discuss the transcutaneous and the percutaneous ways of stimulating the tibial nerve. Let's start with transcutaneous. So when you're stimulating on the skin, and I really like this method of stimulating the tibial nerve because it's something that you can do at home. So the, the first way that you can stimulate the tibial nerve is with a tens unit and patches that you put along.

The nerve. So you can purchase a TENS unit, which stands for transcutaneous electrical nerve stimulation, and then it's just a little handheld device. There are wires that come out of it, and then you attach the wire to some disposable adhesive patches that you have to place along the inside part of your ankle in a very specific position.

You place two of the patches and then normally we have you stimulate the nerve daily for a prescribed amount of time. So somewhere between six to 12 weeks, and again, this can be done at home. It's not FDA approved, but there's been some data that has shown that this is effective and that it's safe. The quality of the data isn't great for most treatments.

For overactive bladder, I would tell you almost everything is about 60 to 80% effective. I think using the patches is a little bit less effective than that. It's more in the 40 to 50% range, and that's just because there's a lot of user error. You can put the patches not quite in the right spot, and so then it's not stimulating things as well as.

But for some patients, this is a very reasonable thing to try because it's relatively cheap. You can put the patches on yourself and you can try it at home. It is an over the counter option, but I would talk to your physician before doing that. You can get a TENS unit on Amazon for somewhere between 40 to $70.

And then the patches, um, are about $20 for 48 patches, which would get you through about three weeks of treatment. There are also different devices that you can put on your ankle that will stimulate the tibial nerve. And the first one that I would talk to you about is the zita sock, ZIDA. I did another podcast all about the Zita sock, and that was in season two, episode 35.

If you want to go back and reference that, their website is live Zita, L-I-V-E-Z-I-D a.com, and with this device you put the sock on, they have a specifically made sock that is size. You attach the device and then you turn it on, and you should wear this for 30 minutes once a week for 12 weeks. Their data says that there's about a 70% decrease in leakage episodes, and again, this falls right into that 60 to 80% improvement that we see with most treatments for overactive bladder.

You do need a prescription on their website. You can download the prescription and you can bring it to your physician. If you're gonna outright buy the device without insurance, it's $3,500. They will charge you $92 a month for 38 months. You can rent it for $549 for that 12 week period. It is covered by Medicare.

And by the va, and it is covered by some private insurances, and this is one of the things that happens with new devices. It takes insurances a little bit of time to start covering them. It doesn't mean that the device doesn't work well. They're just kind of captured in this gray area before. There's a lot of data demonstrating that it's working well and the insurance companies have gotten on board.

So the other device that you can use to stimulate the tibial nerve is called the vile, V-I-V-A-L-L-Y. You can get more information about the Bali at their website, which is eva A-V-A-T-I-O n.com. And I also have a podcast episode all about the Bali, which is in season two, and it is episode 27. So the vile is a boot that you put on.

It's been FD, a cleared. You wear it for 30 minutes, three times a week. It has a closed loop controlled stimulation, which theoretically works better than the other, um, types of stimulation. It makes sure that it is stimulating the nerve in the correct way, and if not, it resets itself. You do need a prescription for the vile.

It's hard to figure out exactly how expensive it is, and they are in the process of working with commercial insurances to get them to pay for it. So again, this is kind of in the gray zone where it's not covered by a lot of insurances yet, as the device becomes more well known. So those are the transcutaneous.

So on the skin treatments for tibial nerve stimulation, there's also a percutaneous nerve stimulation and the percutaneous tibial nerve stimulation you place. An acupuncture like needle right along the nerve. You have to do this in the office, but you place the small needle. It's similar to acupuncture.

You hook it up to a small device that releases a current of electricity. You turn it up to a place where it can be felt, but it's not painful, maybe a little bit above just sensation, and then you stimulate the nerve at this comfortable setting for 30 minutes, and that needs to be done in the office once a week for 12 weeks.

It is pretty common for women who are undergoing PTNS. So that's the percutaneous tibial nerve stimulation to have no improvement for six weeks. So you can do this for six weeks, which is a lot of energy on your part, not notice any improvement. And then after the six weeks, you start noticing an improvement.

With maximal improvement at about 12 weeks. Once you complete that 12 week session, you do move into a maintenance phase, and in the maintenance phase we need to stimulate the nerve, but we do it at the greatest frequency. So that you're not coming into the office that frequently. So you know, we want to figure out how long you can go between treatments and still maintain that effect.

And for some patients, that's once a month. For some patients it's once every two months. It can be longer than that. It can be shorter than that. If it's much shorter than that, it may not make sense for you to undergo PTNS because the maintenance is so frequent and it's hard to come into the office that frequently, and that, again, is very patient dependent.

PTNS has been available in the United States since 2005. It is FDA approved for the treatment of overactive bladder, and again, the research shows that it's 70 to 80% effective. The biggest problem with this particular treatment technique is getting to the office. That's the big barrier that that patients have.

So again, there are two implantable devices on the market right now. The eco and the Revy, and I'll be talking about them again in the next couple of podcast episodes. There are two more implantable tibial nerve stimulators that are coming to the market. So they're doing the research right now and they're pretty far along, but they're not commercially available right now.

I really like tibial nerve stimulation because there aren't any systemic side effects when you do that. So when you take a medication, you can get side effects, dry eyes, dry mouth, constipation might affect your blood pressure. It might make you feel lightheaded. Those things do not happen with this type of treatment because it is very specifically treating a nerve.

That impacts the bladder. So I think that is great for people that have other medical conditions, for people that are on a lot of medications. For people who don't wanna be on medications, it's nice to have something that is fairly specific. I also like to be a nerve stimulation because there are so many different ways that you can stimulate the nerve.

There are ways that you can stimulate this nerve at home. And so I, I think there's kinda something for everybody here. If you want to just stimulate the nerve and not have to think about it, there are implants that would do that for you. If you're someone who wants to be able to stimulate it at home, you don't wanna have a surgery and you wanna be able to do it at the frequency that works for you, then I, you know, think one of the transcutaneous devices are, are a great option for you.

I also think it's nice to be able to try one of the non implantable methods of stimulating the tibial nerve before you go on to doing an implant. So you can basically try it and see how well it works for you. So if stimulating the nerve transcutaneous. Percutaneously works well for you, then I would assume that doing an implant as long as the implant was placed correctly should also work well for you.

So it's nice to try things before you do anything that's a little bit more invasive. So I hope that helps orient you to tibial nerve stimulation and to neuromodulation what we mean when we say that nerve. It just means that we're directly impacting the nerve in some way, and with overactive bladder, we're trying to decrease the nerve stimulation of the bladder and decrease those contractions.

If you're interested in learning more about the implantables, then tune into the next couple of episodes. And you know, I think overactive bladder is the type of medical condition that is very. Depressing for patients. Sometimes patients feel very, very hopeless about overactive bladder, and my message to you would be that there are always more things coming out on the market and with these new treatment.

Types. There's really something that can help everybody. And with tibial nerve stimulation, you could be on tibial nerve stimulation, you could also have a medication. There's no interaction there. So there are multiple things that you can do. So let's go ahead and let's get started.