Trans-tibial Nerve Stimulation and Overactive Bladder
Leeanna Maher PT, MSc PT, H.BSc
Overactive bladder (OAB) is a condition that can significantly impact one's quality of life. Frequent urges to urinate throughout the day, sudden urinary urgency associated with varying levels of unintentional urinary leakage, and multiple night wakings with the urge to urinate are classic symptoms associated with this condition. While there are various treatment options available, a promising approach is the use of trans-tibial nerve stimulation (TTNS).
Understanding Overactive Bladder
Overactive bladder is characterized by involuntary contractions of the bladder detrusor muscle. Normally, the bladder has internal receptors that send messages to the brain to inform when your bladder is getting full. At a certain point, the brain recognizes the signals as a full bladder and, when the timing is right i.e. when sitting on the toilet, sends messages to the bladder to contract while the pelvic floor muscles relax. This opens the sphincter that surrounds the urethra allowing urine to pass from the bladder, through the urethra, and out of the body. When the bladder is filling, the bladder muscle is relaxed and the pelvic floor muscles have a normal level of tone that keeps the urethral sphincter closed around the urethra. As the bladder muscle gradually fills with urine, the brain is able to perceive the sensation of a filling bladder but is able to wait and defer as needed to allow the bladder to fill further. With OAB, the signals of a full bladder happen with much smaller volumes of urine and the signals can be much more intense such that deferral of emptying the bladder cannot happen. Factors such as a urinary tract infection, hormonal changes, neurological disorders, medication side effects, diseases that affect the brain and spinal cord like MS or stroke, and pelvic floor dysfunction can contribute to the development of OAB.
Conventional Treatment Options
Traditional approaches to managing OAB often include lifestyle modifications, pelvic floor exercises, medications, and in more severe cases, surgical interventions. While these methods have proven effective for many individuals, TTNS may be used as a conjunctive therapeutic approach alongside more conservative methods as it is minimally invasive, easy to use, and has fewer reported side effects.
Trans-tibial Nerve Stimulation Explained
Trans-tibial nerve stimulation is a non pharmacological therapeutic technique that targets the tibial nerve, a major nerve in the leg, to modulate neural signals in the sacral plexus associated with bladder function, thereby increasing bladder storage capacity and reducing urinary urgency. This approach involves the use of a small, handheld device that delivers electrical impulses to the tibial nerve, ultimately influencing the neural pathways related to bladder control. Stimulation can be achieved via a percutaneous needle electrode inserted at the tibial nerve near the inner ankle or transcutaneously through a surface electrode patch that lies on top of the skin. The transcutaneous strategy allows for treatment to be integrated daily through a home unit that the client can use independently and over a 30 minute session.
How Trans-tibial Nerve Stimulation Works
Stimulation of the Tibial Nerve: A small electrode is placed near the ankle, targeting the tibial nerve.
Modulation of Neural Signals: Low level, pain free, electrical impulses are delivered to the tibial nerve, influencing the neural signals associated with bladder function.
Bladder Control Improvement: By modulating these signals, transtibial nerve stimulation aims to improve bladder control and alleviate symptoms associated with OAB.
Advantages of Trans-tibial Nerve Stimulation
Non-Invasive: Unlike some surgical interventions, transtibial nerve stimulation is a non-invasive procedure, reducing the risk of complications.
Minimal Side Effects: Many patients report minimal side effects, making this treatment option well-tolerated. Some OAB medications have side effects including increased blood pressure, constipation, and headaches.
Targeted Approach: By directly influencing the tibial nerve, this method offers a more targeted and focused approach to addressing OAB symptoms.
Cost Effectiveness: TTNS can be used at home with the purchase of an affordable hand held unit and does not require frequent visits in clinics where a trained clinician would apply the needle electrode as is required with the percutaneous approach.
Who would not be appropriate for TTNS?
Those who are pregnant, epileptic, have a pacemaker, open wounds or diminished sensation at the ankle site are not appropriate for TTNS treatment.
Clinical Evidence
Numerous studies have explored the efficacy of transtibial nerve stimulation for OAB. Although the exact parameters and location of application varies considerably between studies, the outcomes of these trials prove quite promising for the application of TTNS. One such study demonstrated a greater quality of life score and a significant reduction of OAB symptom severity with the concurrent use of TTNS when compared to the use of the medication Oxybutynin alone (a medication used to decrease muscle spasms of the bladder). The improvement in symptoms were also found to be longer lasting with the addition of TTNS.
Another randomized trial compared the use of TTNS versus the use of Oxybutynin alone. Both groups demonstrated comparable and statistically significant improvements in their OAB symptoms. This outcome may be of interest to those who are looking to trial alternative therapies to oral medications and are wanting comparable effectiveness.
Studies have also demonstrated that the concurrent use of TTNS along with pelvic floor and bladder retraining showed significant improvements in severity of incontinence, frequency of voiding, incontinence episodes, nocturia, number of pads used, symptom severity and quality of life parameters as compared to pelvic floor muscle and bladder retraining alone.
The parameters for TTNS, if appropriate, would be set on a handheld TENS unit by your pelvic floor physical therapist. Under the supervision of the pelvic physiotherapist, the client would then trial the modality during a treatment session in order to ensure familiarity and comfort with the device. Education would be provided to ensure the client is aware of the expected sensation when the device is turned on and a guide for frequency and duration of treatment would be clearly communicated.
Transtibial nerve stimulation is a promising adjunctive treatment alongside first line therapies such as bladder retraining, urge suppression strategies, pelvic floor training, and hydration goals for those managing overactive bladder symptoms. The use of TTNS compared to the percutaneous method demonstrated similar and comparable benefits although TTNS is a more appealing method simply due to its minimal invasiveness, ease of use at home, and cost effectiveness.
References:
Souto SC, Reis LO. Prospective and randomized comparison of electrical stimulation of the posterior tibial nerve versus oxybutynin versus their combination for treatment of women with overactive bladder syndrome. World J Urol. 2014;32(1):179–184. doi: 10.1007/s00345-013-1112-5.
Manríquez V, Guzmán R, Naser M, Aguilera A, Narvaez S, Castro A, et al. Transcutaneous posterior tibial nerve stimulation versus extended release oxybutynin in overactive bladder patients. A prospective randomized trial. Eur J Obstet Gynecol Reprod Biol. 2016;196:6–10. doi: 10.1016/j.ejogrb.2015.09.020.
Furtado-Albanezi D, Jürgensen SP, Avila MA, Correia GN, Driusso P. Effects of two nonpharmacological treatments on the sleep quality of women with nocturia: a randomized controlled clinical trial. Int Urogynecol J. 2019;30(2):279–286. doi: 10.1007/s00192-018-3584-8.
https://www.sciencedirect.com/science/article/pii/S187706572100004X?via%3Dihub
https://www.myrbetriq.com/side-effects/