2025 Urogynecology for the Advanced Practice Provider-Overactive Bladder Refractory to Behavioral and Pharmacologic Management: Advanced Treatment Options

Overactive Bladder Refractory to Behavioral and Pharmacologic Management: Advanced Treatment Options

Video Transcription

Our next speaker is Dr. Michael Gray. He's a nurse practitioner and professor in the Department of Urology and School of Nursing at the University of Virginia in Charlottesville.  He's licensed as a family and pediatric nurse practitioner and holds additional certification as a urologic nurse practitioner.  He's the editor-in-chief of the Journal of Wound, Ostomy, and Continence Nursing and a board member of the Society's Center for Clinical Investigation.  He has lectured both nationally and internationally on topics related to urologic nursing, wound, ostomy, and continence nursing, and evidence-based practice.  He's a fellow in the American Academy of Nursing, and he's the past president of both the Society of Urologic Nurses and Associates and Certification  Board for the Urologic Nurse and Associates. Please help me welcome Dr. Gray.  Good morning. As always, I'm delighted to be here. And we're going to talk about, it's a lovely follow-up to Dr. Carterbrook's lecture.  I'm just going to tell you, that was a superb lecture. That was stellar. She unpacked so many excellent and important points.  And one of the ones that seemed to guide a lot of your questions was the question of nocturia and how does nocturia tie into this.  Overactive bladder and nocturia are two chronic conditions. They overlap, but they are increasingly recognized as two distinct and overlapping conditions.  And some of the excellent insights about urine production at night deserves to be unpacked. Tragically, my lecture won't do that. Again, I do a bit with urodynamics  on a regular basis now. I'll let the objectives sit there just for a moment. And let's get moving. You already know what it is. You've already heard about everything.  The nocturia, it's interesting. The level's been set at one or more episodes per night. There are some epidemiologic data that suggests that one to two episodes may be normal,  at least in the majority of the population, and particularly after age 65. I think we're all scratching our heads as to how much nocturia is clinically relevant.  I would say certainly two or above appears to be somewhat clinically relevant. Again, a bit about urgency. I think you need to just remember  when you're talking and asking your patients about urgency, there are two symptoms that we're dealing with here. The first symptom is urgency with fear of leakage.  And that's overactive bladder. So I ask my patients, you get the urge to go. You're dying to go. You've got to go right now. Why do you have to go right now?  And what would happen if you could not access a toilet rapidly? If they say I'd leak, that's very helpful. If they say it hurts and I would hurt more,  that's called nociceptive pain-induced urgency. And that's going to lead you down that PBS painful bladder syndrome slash interstitial cystitis.  I'm going to speak a little bit about that, though not in detail this afternoon. Again, nocturia, I've given you a few little things about nocturia because I did want to point out  some of those things. There are three things that keep someone in bed at night and not up urinating. Number one, one has to have bladder capacity  sufficient to be able to hold the urine that's in the bladder. Number two, sleep quality, very important. Number three, nighttime urine production,  particularly during that main sleep period. So increased urine production, 24 hours, that's just regular polyuria. Many things cause that.  You just heard about lower extremity edema, chronic venous disease, and all the things that lead to that, congestive heart failure, Mary Palmer's research, so on and so forth.  Quality of sleep, we don't have enough evidence about quality of sleep. And we certainly know that disorders, and which is where we're going to focus about learning track,  can the bladder store urine? Overactive bladder means that they can't. So again, it's more than a learning track symptom. It's a distinct disorder, as I'm pointing out here.  I'm going to talk to you about some guidelines from outside of OGS, including those from the American Urological Association and the Society of Urodynamics and Female Urology.  I will say that the guidelines are beginning to move away from this idea of first, second, and third line therapies. Let me ask you some pragmatic questions. They're rhetorical.  You don't need to answer them, but you're welcome to shout out at me any time you want to. But essentially, your patient walks in.  They have frequency, urgency, nocturia, urge incontinence, so-called OAB wet. Don't like the term, but I'll live with it, OAB wet. And you talk to your patient.  Do you send them home for six or 12 weeks and say, just try the behavioral stuff? It's a good likelihood you're going to go ahead and offer at least some pharmacotherapy.  You see what I'm saying? When I'm doing so-called third line therapies, percutaneous tibial nerve stimulation, I'm frequently talking to my patients about behavioral interventions.  So I'm literally going back to so-called line one. So the idea is that they're trying to remove that. The insurance companies aren't with us yet,  so you're going to have to live with it for a while. But the guidelines are trying to get ahead. Again, I think that behavioral therapies is APP 101.  We do, and we must always integrate those behavioral therapies throughout treatment. Never think your patient is beyond hearing about that.  The first time a patient is seen, they may be told, oh, just stop drinking caffeine. It sounds so easy. It's not easy. And the other thing is, if a patient  has been on one medication, even if it's a medication in the same drug class, anti-muscarinic versus beta-3 agonist, simply changing the molecule.  We don't have good genomics for pharmacotherapy. Changing the molecule may make a big difference. So we're going to talk about advanced therapies.  I'm going to focus on minimally invasive things. I'm not going to talk as much about the surgical approaches, which are certainly legitimate. Again, additional evaluation, I do  think it can be time for urodynamic testing. I've just given you two very broad examples here. If you look at the top one, you see two things going on that are important to us.  First off, if you look at that urodynamics and you look at that cystogram that I've shown you, that's when the patient was undergoing stress testing,  coughing, for stress urinary incontinence, classic abdominal leak point pressure testing. Obviously, that bladder's not quite up where we want it to be, at this inferior margin,  the sempsis pubis. It's herniated way down into the vaginal vault. If you look at that voiding pressure flow study and focus on that red line, you see  that she's voiding with high pressure. She's got rather prolonged and low flow, well below the cut point of 15 mLs per second,  which is considered to be the minimum acceptable on avoiding pressure flow study in a woman. And lo and behold, this woman not only has prolapse,  she's got some obstruction, and she has classic detrusor overactivity. So then the approach becomes much more complex, and in this case, likely will involve referral  to a urogynecology surgeon, one of the urogynecologists, for further treatment. And then the one down below, let's see if I can get my second, there it is,  my second little one to show up. You've already heard about suburethral diverticula. If you look at those, they're periurethral diverticula.  If you prefer that term, if you look at that periurethral diverticula, I can also tell you that the lady down below has had two strokes.  And I love the idea. If you touch it, she'll have a little bit more discomfort. Clearly, some of my residents' touches are perhaps a little bit more stern, tragically,  because jumping off the table was the analogy I might have come with. It can be very painful to touch that. You can see the agglomeration in that second one, that big stone.  It's not really a well-formed stone, but it's a big old agglomeration. It's an inflammatory mass. So therefore, it is time now to unpack urodynamics  when we're getting some of these therapies. Again, so I'm going to talk about three things here. They're no longer called third line therapies in my little world, but they  are intradetrusor botulinum toxin A, or onobotulinum toxin A, sacral neuromodulation, and percutaneous tibial nerve stimulation. There's two alternatives to that.  They're now implanted devices. We're going to talk about that. There's always been transcutaneous. That tends to wander a little bit out of controlled health care delivered care.  And we'll talk about some of the problems when you tend to do that type of thing. So let's start out by talking about, I want to use Botox as a shortened term for that.  So it's given intradetrusor. That means that it's endoscopically administered. It's 20 injections of about 0.5 mLs into the bladder under guidance, obviously.  Most of these individuals who are receiving this, unless they have pretty diminished sensations in the bladder, feeling pretty much almost essentially  neurological loss of sensations in the air, are going to have to have some sort of assistance with some midnight dosing or something like that, up to full-blown anesthesia.  The injections are about going to be a centimeter apart, about 2 millimeters deep. There's lots of vendors will show you lots of ways to do that.  You're going to get about six months out of it. You can get nine months. In rare cases, they'll get 12 months. But about six months has emerged.  It's about the standard time that they're going to get out of it. Do APPs do it? I don't have a good, I haven't found good research in our PA colleagues.  But I can tell you, I have found good, reasonable research in the APRN. And it said that 31 were directly involved in injections.  They didn't exactly ask them, were you doing the injections? But they did indicate that they were directly involved in injections. And I certainly have anecdotal reports of APPs  who are doing injections. I'm in a university. I can't imagine being all that thrilled about doing injections. But if it's part of your practice, make it so.  And I really support you in that. It's a potent neurotoxin. You already know that. You know that it acts postsynaptically. Essentially, it was proven about 2011, about 2013.  It's comparable efficacy to that of sacral neuromodulation. The folks that I work with get all waxed. They wax all aggressive about sacral neuromodulation because it's real surgery.  And they kind of foo-foo Botox. Is it just endoscopic? Do that in the office. So on and so on and so forth. But actually, you'll find that they're gonna be  about the same in efficacy.  Again, as your patient gets older, the adverse side effect profile predictably goes up. The big adverse side effect profile will include urinary retention.  And as your patients get older, you're talking an average of six weeks of intermittent catheterization versus indwelling catheterization.  So some of these side effect profile are significant. Let's look here at essentially the mechanism of action. If you see down there, you can see the snare complex,  the idea of these snare proteins, the SNAP-25s, as they're calling it. And the idea is that it doesn't allow things to, look there, you see it's broken up,  that SNAP protein or that snare complex. So little vesicles full of acetylcholine can't get down there, release their neurotransmitter and cause the bladder to squeeze.  Okay, it's fairly interesting. Again, under, I'm just showing you pictures there. There was one recent report that I'm adding in to you  and that is monitor blood pressure during injections in those with hypertension. It's a small study, it's in the World Journal of Urology.  They're about 70 women and there was a mean increase in diastolic blood pressure of about 20 points. But look at the range, the highest systolic blood pressure,  systolic, not diastolic, the highest systolic blood pressure was 232 over, you see what I'm saying? So it can be a little impressive. So if your patient has poorly controlled,  hypertension or you're worried about hypertension, just have some of your folks monitor that during intradetrusor Botox injections. If you're the person giving it,  just bear that in mind for yourself. Again, is there an increased risk for urinary tract infections immediately following Botox?  Because of the procedure, I think the answer to that is yes. Is there somewhat of a sustained, there's a theoretical risk for that. There's been shown that individuals  that have neurogenic lower urinary tract dysfunction are at greater risk than those individuals who had idiopathic. If you look at the pivotal trials with the idiopathic patients,  there was no real statistically significant difference between in the infection rate based on injecting Botox.  Urinary retention rates, I've already told you that. It's about, again, a couple of percent. The mean duration though is about six weeks, particularly in older folks.  If your patient walks in with an elevated post-void residual, which is reflective, particularly in women, likely reflective of underactive detrusor function,  weak bladder muscle squeeze, then there is going to be an increased risk of her experiencing.  And you need to ask me, well, then what's the cut point? And the answer is, you know as well as I do, we don't have a good cut point.  But I will at least say if your patient has 250 mLs or above, that's a pretty conservative or pretty high cut point. You certainly need to be aware of that.  There is a box warning with all forms of botulinum toxin and that is systemic spread. The idea is that any kind of skeletal or smooth muscle that it interacts with,  it's gonna get rid of those snare proteins, which means it's going to relax those muscles. It can go systemically. It can relax the respiratory diaphragm.  That can lead to, unfortunately, respiratory distress and hospitalization with critical care required for a brief period of time. Swallowing and breathing difficulties, less severe,  but that can also happen in a highly small. That's an atypical response, but you just want to be aware of it.  Again, we talked about the UTI. This is a randomized controlled trial.  And they looked at two things. Should we be giving suppressive antibiotics? So far, the evidence is not particularly great. The first one was 137 women who received antibiotics  and unfortunately, there was no significant difference between UTI rates if she got an antimicrobial or she didn't get an antimicrobial. I'm talking about day of the procedure.  I'm talking about a short, generally about a seven week  trial or five to seven day, not week, five to seven day course of antibiotics. Second was observational, so non-randomized trial. And again, no statistically significant difference.  So can I tell you that because of that theoretical risk for increased UTIs that a week's or five day's worth of antimicrobials is going to do what you need?  The answer is I cannot tell you that that is something that you need to be doing. I don't have the evidence to support it. So we've talked about intradetrusor Botox.  Let's move forward to PTNS or percutaneous tibial nerve stimulation. As of 2025, there are two commercially available systems. You see pictures of both.  I've obviously covered up any branded names for CE requirements and happy to do so. They both are battery operated. They both are going to have, I've used both of them.  They have a broadly similar delivery rate. They have different batteries and slightly different care requirements, but those are very minor differences.  Again, it uses a 34 gauge needle. And those of you who are familiar with acupuncture, that's the same gauge or size needle. This is not acupuncture.  I just want to really emphasize that. This is not acupuncture. But placement of the needle, we can certainly learn from acupuncturists, okay? The way that they place the needle,  the way that they advance the needle with their little spinny, they have a little spinny way that they advance that, and it's quite interesting.  Essentially, we're talking about something that's comparable to antimuscarinics, generally compared to tolteridine. No surprise there, tolteridine's a bit  of an interesting molecule in terms of the antimuscarinics. It doesn't have a good dose-related response, and it has some other issues that are going on with it.  But nevertheless, it also is more effective than sham. So this is not a placebo effect. This is not an entirely placebo effect. There's a real effect that is positive,  and that's why it's reimbursed by various insurance providers. I think it's a great procedure visit for an advanced practice provider.  You're gonna start them out with 12 weekly sessions, 30-minute treatments each session. If the initial response to treatment is greater than 50% improvement in symptoms,  then there is, that you can get an extension to monthly maintenance system. So that means you're gonna do three months of 12 weekly, provided they're progressing  through that series of initial treatments, and then you can take them to nine monthly maintenance sessions for a year. Now, the CMS policy that many, many,  I'm not gonna say most, but with exception of TRICARE, to my knowledge, most will say, will adhere to the CMS policy, which is a two-year treatment holiday  after that one year of PTNS treatment. My only problem with that is, and again,  just like the previous lecture, this is a chronic condition, and the treatments are not, you don't just fix OAB.  It's ongoing treatment. It's chronic. It tends to remit and then have exacerbations.  Trauma is an exacerbation, right? That's a very potent exacerbation. I've seen emotional traumas, death in the family,  disaster in the family, you know, the house burns down, blah, blah, blah, blah, blah, and when we see our patients, they do tend to recur.  I've had patients who have, who've had, you know, cardiac, cardioversion, you know, these types of thing, and they'll tend to have a recurrence of OAB.  So this idea of this magic two-year holiday, I'm not real thrilled with it, but we have to live with it. And there we are. It's pretty easy to do. It doesn't take rocket science.  You can see her malleolus. You can see where they're locating. It's supposed to be two finger breads above and one over. The only problem with all that kind of stuff is,  to be perfectly frank, I have sausages, so I'd be putting the needle in the knee or something like that, you know, or in the exam table or something crazy along those lines.  So what I can say is just visually look at it, but the idea of the finger breads, if you have nice little lovely fingers, that's wonderful.  You're going to put some sort of a reference electrode, which you can see being placed here, and then you're going to hook it up to your device. And I put the needle in a bit lower.  I do put my needle in at about 45 rather than 60 degrees. I don't find 60 degrees to be as helpful as 45 degrees. So I'm going in kind of low. There is an urban myth.  If you look at some of the YouTube videos, the needle is pointed up. And I've been told by multiple reps from both companies, well, that's because you want the treatment  to go up toward the spine. Okay. It's a nervous system. We're talking about electrical currents. I'll let you use your own physical ability to realize  that that's just a nice thought. There's something wrong with pointing it up toward the sacral spine. I tend to point mine down, which is actually the original picture up there.  I tend to go in low and gently toward the malleolus. And I also deal with exactly what you're talking about. These patients have great big old ankles, right?  Many of my patients have big, big, big, big ankles. And so therefore, you know, you hear 25% or I am often going in 80% in and then almost up to 98 or 100% in.  That's to the point of the insulated bit on the end. You want to get them to report tingling. A lot of my patients say it's like a bunch of little L's  with little hammers beating on the back of my foot. You want it to be isolated away from the needle if they point to the needle only, you are not giving good treatment.  You want it to be in the, anywhere in the plantar surface of the foot. In many of my patients, it'll shoot up towards the waist. So they say, I feel it running up towards the waist.  It does vary. You want to look at a motor response, you either get the classic toe curl in the upper one right there. You see that being there.  Or you literally, the feet will fan like this. The toes will fan just like this. In many of my patients, they have such severe peripheral neuropathies  that they feel very little or nothing. However, if you do hit the tibial nerve, you will occasionally get the tip of your needle probably within a millimeter  or perhaps physically at the tibial nerve. So if your patient, when you put the needle in, reports that they already feel like they're having a strong treatment  or it tends to defer, run up the, essentially run up the leg toward that, or you see a motor response, you might want to back out about, oh, two or three centimeters.  I had a patient who had had a stroke  accompanied by a partner.  Patient is seated with help from, sorry, I have to talk about a male patient rarely, seated from, across from his partner. And she explained to me, he's not spoken in several years  because of expressive aphasia from his stroke. I apparently hit the nerve. Lordy Jesus, I feel that. We both about jumped out of our skins.  And I'm sharing that example as the extremity. They will really feel a very, very powerful stimulation, even though I'm probably giving less than a volt.  Remember the nerves work on microvolts. So I just want to be aware that if you get that, pull it back a little bit, you can always go a little bit in and out with that needle  and get a little bit stronger or weaker, depending on where you've located it.  Okay, again, some people say it throbs. Generally, you want to go to the highest awareness threshold and below the pain threshold. I've had colleagues who've said,  no, I make them hurt a little bit. And I'll be honest with you, what they tend to find is adherence drops off because it becomes a treatment of dread.  I have no data at all that supports higher treatment levels,  meaning greater volts being delivered, microvolts we're really talking about, but greater voltage being delivered as more effective than somewhere above the sensory threshold.  Somewhere above the, so I would go above the sensory as strong as you can get it while remaining below the pain threshold. So that's going to take about five minutes  when you get experience. It's going to take about three minutes to do that. And you're now going to have 27 minutes. I would love to tell you that I had the luxury  of sitting in there and chatting with my patients for that 27 minutes. I don't, I'm running around like you are. However, I do use at least 10 of those minutes  and I talk about behavioral therapy. And I find that that is extremely useful time to spend. Caffeine, we didn't have a lot of time to talk about caffeine, but I love that.  I don't tell them to stop caffeine forever. That's the biggest advice that I give my patients as well. I couldn't agree with that more. Why?  Because caffeine has, and I'm giving one example only, caffeine has positive impact on all cause mortality.  It may be somewhat, we don't know the magnitude of the contribution, but it may be somewhat helpful in avoidance of or prevention of even  classic Alzheimer's related dementias. It's weak correlational evidence, but it is a positive, a consistent trend.  Okay, so am I going to tell my patients never consume caffeine? So you need to sit down and you really have that ability to sit down and speak to your patients  because you're push, push, push. We're all in the same boat. And so it gives you just that couple moments of counseling. So if you can use that counseling,  there's a thousand things you can talk about. Again, I was gobsmacked, so thrilled to hear this. Talk about, again, edema in the lower extremities.  Actually talk about support stockings. That's incredibly important. It's something that's not tied into this. I'll give you one more advice that you can talk about  just because I think this is that important. Talk about the timing of diuretics. How many patients should prescribe diuretics and they take it in the morning?  Think about circadian rhythms. When is the body driest? Answer, in the morning after the first morning pee. When is the body going to be the wettest?  Answer is, particularly in folks with dependent edema, congestive heart failure, other comorbid conditions associated with polyuria or nocturnal polyuria, right as they go to bed.  So when do we give them their diuretic? When do they get their furosemide or whatever ozomide we're giving them or whatever thiazide we're giving them?  The answer is, oh, you have to take that with breakfast in the morning. Try two in the afternoon.  Abrams did research on that and he found a median reduction in nocturia episodes of one.  If your patient cannot get a single four-hour sleep period, then she will tell you she's gonna have chronic drowsiness and she's gonna have chronic lack of sleep.  The chronic psychological impact of that is devastating.  Devastating. If you can give her a single four-hour period of sleep,  you will improve her sleep hygiene, you'll improve her wakefulness, and you will reduce the distress, legitimate physiologic distress associated with chronic sleep deprivation.  So let's be talking about third lines. So how much is enough? I believe we've talked about that adequately. Are there implantable devices? There are now two implantable devices.  I've shown them on this one. Again, I'm gonna avoid branded names.  The one is, as you can see, this is from their website and they're analogizing it to a nickel. That's because it has similar dimensions.  It's just a couple of millimeters less in diameter and I believe it's maybe a millimeter or so, maybe two millimeters less in thickness  than the nickel that you might have in your pocket.  The other is a little rod. So if you look down there at the little rod, it's about 2.5 in length and it's about three and a half millimeters in diameter.  The one up top that I'm gonna call the nickel-like one for the moment, that one has a battery that's implanted into your patient's body.  And you see where it's implanted, almost as if we were doing the PTNS, rather than going percutaneously, we're now using that. And then the other one is a rod.  You see it's implanted in a very similar position. The rod relies on an external battery-operated device  in order to provide stimulation. So one is inside the body, the other is outside the body. There are lots of anecdotal reports. I don't have any evidence to quote you.  There are anecdotal reports about, well, you know, the battery going out early and so on and so on and so forth. Let me just say that those,  you can decide in your patient population. The coin-shaped implant, again, I can show you some efficacy there.  A lot of this has been compared to baseline PTNS, and you're typically gonna find equivocal outcomes.  The coin-shaped looked at about 46 patients. The rod looked at about 155 patients. Both use idiopathic OAB with URG and CONUS  because it's easier to measure outcomes in those patients, I understand completely. And you can see that both had statistically significant  improvements that were clinically relevant. You're talking about 70, 75% with PTNS. I generally quote my patients about 70% in idiopathic overactive bladder.  With neurogenic overactive bladder dysfunction, I tell my patients that the response rate is anticipated to be less. I give them about 50%,  and if I've gotten any higher data than that, then I'm happy to take the praise for that. Both use external devices. You can see one that's in a little wrap that would be around,  and then the other one is a little remote device that would just be placed somewhere near you. You don't wanna place it in Florida if they're having treatment in New Jersey.  So the idea is you just wanna have a little remote device. It's pretty much close by to the individual. They would do these treatments at home.  They would do these treatments at home. I attended another meeting in another specialty called urology, and what when the surgeon said was,  well, that's it, I'm never gonna do PTNS again. There's not an ankle in the world I can't get that device into. I see a significant number of patients  who have chronic venous disease and are CEP3s and CEP4s, and I defy any surgeon who's willing to put a coin in a patient who has such poor wound healing  that they have had a history of venous leg ulcers. So I think that PTNS will continue to play a very significant role. Many of my patients want to come in  and have supervised treatments. I'm shocked that I thought that my entire population of PTNS patients would go away. Our population has stayed entirely stable  despite the fact we have an excellent female urologist, and I'm sure one of my urogynecology colleagues just down the hallway are beginning to do it as well.  I just couldn't tell you who and when they started doing it. We just don't see that massive shutdown of PTNS. So I'm gonna tell you, have each of these in your mind.  I think that young folks who wanna have an implanted device, folks who don't have a contraindication, it must be offered and should be really advocated.  Folks who do not want to do that, who are willing to come in, many of my older folks, quite frankly, relish those abilities, sit down with a provider, you know what I'm saying,  and actually talk about some of their LUTs. And it does allow you to, you know, I'm able to do little mini lessons. Let's talk about fluids this week.  Let's talk about caffeine next week. Let's talk about irritating foods. That's a luxury I never have. I just never have. So it does have some advantages to that.  There's only been one systematic review that I could find that looked at these implantable tibial nerve stimulation devices, and they didn't compare it to PTNS,  they compared it to the sacral neuromodulation devices. And again, it was 20 studies, looked at just under 1,800 patients. And what they found was that  the urgent continent rate was similar. The OAB responder rates were similar. No significant differences in adverse effect incidence. So they are equivocal, broadly equivocal  treatments for overactive bladder. Transcutaneous, I'm now wandering a little bit out because there is no TTTNS, you know, there's no device that's just for that.  What you're gonna get is your patient is going to purchase often on the open market, you know, the big box companies where everybody orders that river,  company where everybody orders everything from, so on and so on and so forth. And basically, if your patient is highly motivated and independent and is good at self-management,  they do pretty good. The results are not quite as promising as are the implantable or the percutaneous. It doesn't mean this doesn't play a role.  It's a little bit more to the edge of our practice. And just to be willing of that. I'm gonna talk a little bit about the sacral neuromodulation devices.  I'm gonna change there again, two commercially implantable devices. The second device that came on the market offered the advantage of being MRI compatible. The first one was not.  So what did the first company do? It took them about a year and they came out with an MRI compatible device. So I think that that advantage may have been slightly washed.  Nevertheless, you'll find that it is,  it's older research. It's been going on since, well, when I was much younger in the 90s. This is not brand new research, not a brand new device.  And it is, again, comparable to intradetrusor Botox,  certainly comparable to PTNS, okay? Certainly, it's so far comparable to the implantable devices as you see. It is surgically implanted, not in the spine,  but as you can see at the sacral root area.  There are some things, it is an APP that you might be involved in. One might be adjusting the stimulation. It has to be up and down adjusted.  I remind you that when that thing is in, the body wants to throw a little inflammatory granuloma around a little bit of scar tissue.  So you have to cut up the stimulation a little bit. You also need to tell them some ongoing counseling. They will light up the airport devices. Please ask them to bring their,  the actual off and on remote device that they have with that. I'm amazed at the number of patients coming to me for video urinamic evaluation. We have big notes that say, you know,  bring it in, bring it in. They say, oh, you know, I forgot that. So I have no choice, you know, I need to be able to cut it off, cut it on.  We have to make a lot of bad decisions based on that.  And again, they need to, they have to bring the modulator device when they travel. They need to be able to have that modulator device with them.  They need to have it with every healthcare visit. Is it effective? I've shown, this is an old, obviously a forest plot analysis. And if you look at that,  you can see that if it's to the left of that line of no effect, which is that big zero line, it actually favors treatment. It all favors treatment.  And again, that's a slightly older Cochran review, but the outcomes have never changed. It is an effective device when implanted in carefully selected patients.  Okay, when implanted in carefully selected patients, just as all these advanced therapies are effective in carefully selected patients.  The adverse effects, pain at neurostimulation device, new pain onset, lead migration in about, you know, just under 10% infection in a small amount,  a little bit of a shock because something went on, pain at the lead site, and adverse change in bowel function is gonna be in a slight minority of those patients.  There are a few other things. I'm not really, I'm gonna talk about them very briefly. The first is an indwelling urinary catheter is a possible option  in an enormously highly select population. They're generally nearing end of life when incontinence simply, you know, they really don't have the mobility  to be able to tool it effectively. So this is a tiny, tiny population. There are 15 studies looking at acupuncture in this particular meta-analysis I brought out for you.  And the very weak, the evidence was extremely weak. There weren't particularly greatly designed trials. Sandy Engberg, my colleague at University of Pittsburgh,  has done one of the best trials I've ever seen on it. And it tends to be a little bit helpful. I had never heard about this, but vaginal laser therapy.  I was reading recently about that. They use either CO2 or erbium YAG.  And the idea was to promote some, you would strip off and then promote regrowth of the vaginal epithelium, collagen remodeling.  I would say insufficient evidence to, for me to be able to make definitive statements to you about its efficacy. It is being looked at.  And of course, finally, pelvic floor muscle therapy. I think it's effective, period. Evidence says it's effective as first-line therapy, the freeze and squeeze.  That comes from Kathy Bergio and Bernie Engel. They originally worked that out at the NIH when there was an NIH, and the National Institute of Aging. And it was fabulous research.  I had the pleasure of being involved and watching them do that. And this idea of urge suppression is an extremely powerful thing. I cannot tell you how much I think  that these patients should be taught urge suppression. It's also one of my many lessons. If I have had the luxury of having a pelvic floor muscle specialist PT,  I feel even more about it. Surgical interventions, again, a tiny, tiny, tiny, tiny, tiny group. This is such complicated OAB. It hardly is recognizable as OAB  by the time they get to these surgical interventions. Thank you for your time. I've got just a few minutes for.

Video Summary

Dr. Michael Gray, a nurse practitioner and professor in Urology and Nursing at the University of Virginia, discusses the complexities of managing nocturia and overactive bladder (OAB), recognizing them as distinct yet overlapping chronic conditions. He emphasizes the significance of understanding urinary urgency and introduces the issue of nocturia as not merely a symptom but a condition requiring specific attention. Dr. Gray outlines various treatment modalities and guidelines, advocating for integrating behavioral with pharmacological therapies. He explores advanced therapies such as intradetrusor Botox, percutaneous tibial nerve stimulation (PTNS), and sacral neuromodulation, emphasizing their efficacy and patient adherence challenges. PTNS is highlighted as a non-invasive and manageable therapy, particularly suitable for hands-on patient counseling, while Botox is touted for its comparative effectiveness against more invasive procedures. Dr. Gray also touches on the impracticality of the current therapeutic holiday mandates dictated by insurance providers, advocating for continual management of the chronic nature of OAB. Audience questions prompt further discussion on specific methodology, implications of diuretic timing, and potential adverse effects, affirming the critical need for personalized and pragmatic clinical approaches.

Asset Subtitle

Overactive bladder is increasingly recognized as a chronic symptom syndrome requiring a multidimensional approach based on shared decision making between provider and patient. This presentation will review treatment options for women who are refractory to behavrional and pharmacologic interventions. Specific interventions will include neuromodulation (percutaneous, transcutaneous, implanted tibial nerve stimulation, sacral neuromodulation), botilinum toxin injections) and several promising investigational intereventions.

Objectives:

Describe the evaluation and management options for women with OAB who are refractory to behavioral and pharmacologic interventions.
Discuss neuromodulatory interventiosn for women with refractory OAB.
Review principles of OAB management using intradetrusor botulinum toxin.

Speaker - Mikel Gray, PhD, FNP, PNP, CUNP, CCCN-AP, FAANP, FAAN

Keywords

nocturia

overactive bladder

urinary urgency

intravesical Botox

percutaneous tibial nerve stimulation

sacral neuromodulation

behavioral therapies