The Introduction to Percutaneous Tibial Neurostimulation at Parklane West for Urinary Incontinence

What is PTNS?

Percutaneous Tibial Neurostimulation (PTNS) is a procedure in which a 34 gauge needle is inserted into the tibial nerve pocket of a patient, connected to the NURO™ device (see figure 1) by Medtronic, turned on to send electrical pulses to the afferent fibers of the tibial nerve, to help patients with overactive bladder (OAB) improve their quality of life.

Who is using this for treatment?

Currently at Parklane West, there are seven patients being treated for OAB under the NURO™ system, two males and five females.

Patient 1: Male. History: diabetes, R BKA, OAB X 2 years, tried a regimen of medications. Number of voids in a 24-hour period before treatment: 16-18.

Intensity settings by treatment: 2, 3, 2, 2, 2, 2, 3, 3

Patient 2: Female. History: HTN, history of falls, DM2, neuropathy, Alzheimer’s stage 1, L TKR, R THA, h/o nephrectomy. Number of voids per night before treatment: 6.

Intensity settings by treatment: 3, 3, 5, 7, 4, 4, 1, 2

Patient 3: Female. History: Stage 3 dementia, ESRD, systolic CHF, HTN, GERD, anemia, DM2, h/o CVA. Number of voids in a 24-hour period before treatment: 8+

Intensities by treatment: 3, 3, 3, 4, 3

Patient 4: Female. History: HTN, leukemia, lupus, hernia. Patient complaint: leaky bladder before each void and having to get up 4+ times in the night.

Intensities by treatment: 2, 8, 8, 5, 3, 2

Patient 5: Male. History: Stage 6 dementia, OAB X four years, tried toileting schedule with caregiver, DM2, repeated falls. Patient unable to tell caregiver he needs to void.

Intensities by treatment: 3, 3, 5, 2, 4, 4, 8, 1

Patient 6: Female. History: R TKA X three years ago, vision problems, leaky bladder with dribbling.

Intensities by treatment: 8, 1, 6, 1

Patient 7: Female. History: A-fib, aortic valve stenosis, hypothyroidism, breast cancer, unsteady gait, normal pressure hydrocephalus.

Intensities by treatment session: 8, 8, 4, 3

All intensities measured in MHz.

Who should not use this treatment for OAB?

  • Patients with pacemakers
  • Patients with defibrillators
  • Patients who are prone to bleeding
  • Patients who are pregnant

What is happening in the treatment?

The patient is in a comfortable position with the lower extremity slightly externally rotated to expose medial malleolus. The area is prepped with an alcohol swab, and a 34 gauge needle is inserted to the tibial nerve pocket. To find the tibial nerve pocket, use three finger widths superior to the medial malleolus, using the middle of the three fingers, move that finger one finger width medial to its starting position. The needle will be inserted with a 60-degree angle toward the toes with two aggressive taps. A motor or sensory response is to be validated or seen before the NURO™ system is attached and turned on. All materials needed are shown in Figure 2. After a motor or sensory response is noted, the intensity is turned on. This will vary per patient. Figure 4 shows afferent and efferent pathways with bladder reflex.

Treatments are 30 minute sessions, once a week, for a recommended 12-week period followed by a maintenance program of once a month for three months. No patient has reported a negative feeling during the insertion process.

Does it really work?

  • Patient 1 started with 16 to 18 voids per day and was sleeping one to two hours a night in between voids prior to treatment. After eight sessions, the patient was voiding seven times in a 24-hour period and sleeping four hours at night.
  • Patient 2 was voiding three to four times per night prior to treatment. After the third session the patient reported one time per night and continues to report that she feels safer getting to the bathroom, as she does not have to rush anymore. Whereas before she used multiple layers in her brief, now she just uses the brief.
  • Patient 3 oids four to five times but gets a signal and is able to make it to the bathroom and has reported drier briefs. The patient is currently working with PT to develop a walk-to-bathroom program.
  • Patient 4 now gets up one to two times per night and is able to sleep longer before having to get up to void.
  • Patient 5 receives a signal to notify the caregiver he has to void. He is able to safely make it to the toilet and sits for a bit before urination is started. He has less urine amount by weight on his pads and briefs in the morning, according to the caregiver.
  • Patient 6 is too early in treatment to demonstrate a noticeable change but reports it has not made her condition
  • Patient 7 reports double the amount of voids after four sessions and held off week

Benefits for patients, clinicians and the business

From the patient’s point of view: There’s more sleep at night and less voiding during the day, and treatment does not hurt; “in fact I can nap while the treatment is being done.” “I make it to the toilet before I start using the bathroom.” “I can tell my husband is not going as much in the night by the weight of his brief and pad.”

From the clinician point of view: The treatment reduces skin breakdown, infection risk and fall risk, as the signal to void comes more quickly and allows more time for the patient to safely get to a bathroom. It also encourages the patient to be more active in the community and allows MDs to focus on more patients now that it is accepted under PT scope of practice.

From the business point of view: The treatment was recently introduced in the scope of practice of physical therapists, and it supports ICD 10 codes N32.81 (OAB), R35.0 (urinary frequency), R39.15 (urgency of urination), and N39.41 (urge incontinence), with CPT code 64566. It is charged as a 30-minute code with a Medicare National Average reimbursement of $130. It increases productivity of physical therapists as it is an unattended procedure, therefore increasing productivity of the team and the facility as a whole. The treatment has the potential to reduce costs associated with UTIs, skin breakdown, falls, etc.

Conclusions/Further research

  • So far at Parklane West, patients are reporting less frequent trips to the bathroom and drier briefs, they’re receiving a signal to urinate, and nursing staff is able to focus on other tasks with less brief changes.
  • As it is early on in the treatment process, we are waiting to see long-term effects over the years.
  • Further research would include PTNS followed by immediate pelvic floor training to increase benefits
  • Further research is needed regarding the benefits of PTNS and reducing fall risk
  • Do some neurological conditions have an opposite effect?

View poster: Parklane PTNS – Urine for a surprise (PDF format)

By the Rehabilitation Team at Parklane West, San Antonio, TX