Tibial Nerve Stimulation for Voiding Dysfunction

16 Aug 2025 13:30 14:00
Hann-Chorng KuoTaiwan Moderator ACU Lecture: Videourodynamic Study for Precision Diagnosis and Management of Lower Urinary Tract DysfunctionVideourodynamic Study in the Precision Diagnosis and Management of Lower Urinary Tract Dysfunctions Hann-Chorng Kuo, M.D. Department of Urology, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Tzu Chi University, Hualien, Taiwan As a urologist, we are dealing with patients with lower urinary tract symptoms everyday. We did transurethral resection of the prostate (TURP) for elderly men with bothersome lower urinary tract symptoms (LUTS). We put a suburethral sling for women with stress urinary incontinence (SUI). We prescribed alpha-blocker for those who had difficulty in urination. We add antimuscarinics for patients with urgency urinary incontinence. Our seniors always told us these treatments are effective in treating patients with LUTS. However, patients still had LUTS after TURP, women still complained of urgency and dysuria after anti-incontinence surgery. Medication based on storage or emptying LUTS do not work all the time. Why? Because symptoms are not reliable, a large prostate does not indicate bladder outlet obstruction (BOO), and SUI is not solely a result of urethral incompetence. Therefore, in diagnosis and management of LUTS, we need precision medicine to direct an accurate pathophysiology of LUTS, and to guide an appropriate management based on the bladder and bladder outlet dysfunction. When we encounter patients who have LUTS refractory to the treatment based on our initial diagnosis, when we are treating patients who have complicated storage and emptying LUTS, when we are not sure patients could benefit from the invasive procedures for their LUTS, or patients who had both lower and upper urinary tract dysfunctions, videourodynamic study (VUDS) is an essential investigation for diagnosis and management of LUTS. In additional to benign prostate hyperplasia (BPH) and BOO, male patients with emptying LUTS might result from detrusor underactivity (DU), bladder neck dysfunction (BND), urethral sphincter dysfunction, or a hypersensitive bladder, which is not related with the prostate. Patients with BPH and LUTS might have latent neurogenic lesion, such as minor stroke, Parkinson's disease, or early dementia, causing LUTS. TURP without known the neurological disease might exacerbate LUTS after surgery. Mixed SUI comprises intrinsic sphincter deficiency (ISD) and detrusor overactivity (DO). The overactive bladder (OAB) symptoms may also result from an incompetent bladder outlet. Without comprehensive VUDS, we might cure the SUI, but OAB remains after placing a mid-urethral sling. Bladder pain is the cardinal symptoms of interstitial cystitis. However, bladder pain perceived by the patient might also originate from BOO or pelvic floor fascitis. VUDS can help in discrimination. DU and low compliant bladder and ISD could result in complicated storage and emptying LUTS. Large post-void residual (PVR) should alert us to investigate whether it is originated from low compliance or ISD. Dysfunctional voiding (DV) and BND in women with emptying LUTS. OAB symptoms are not always coming from the DO. BOO such as BND, DV, or urethral stricture might exist in men and women without voiding symptoms. Urinary difficulty in women is usually a result from low detrusor contractility, due to DU, or through inhibitory effect from a poorly relaxed pelvic floor or urethral sphincter. A simple bladder neck incision can effectively restore spontaneous voiding in men or women with dysuria due to DU or BND. However, a tight BN is necessary to predict a successful treatment outcome. Patients with central nervous system (CNS) disorders or spinal cord injury usually have complicated LUTD, including DO, BND, DV, detrusor sphincter dyssynergia (DSD), and vesicoureteral reflux (VUR). Management of LUTS in CNS disorders or SCI patients should know the current bladder and bladder outlet dysfunctions. Pediatric incontinence, children with myelomeningocele, DV, or recurrent urinary tract infection are complicated and need precision diagnosis before treatment. Especially when surgery is planned. Lower urinary tract dysfunctions is a dynamic condition. The bladder and bladder outlet dysfunction might change with time. Although VUDS is considered as an invasive investigation with radiation exposure, the advantages in accurate diagnosis and guiding management outweigh these disadvantages.
Marshall StollerUnited States Speaker Normothermic Ex Vivo Kidney Perfusion for Urologic Discovery
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This presentation details the evolution and clinical applications of Percutaneous Tibial Nerve Stimulation (PTNS) as a minimally invasive therapy for a range of bladder dysfunctions. Building upon the foundational work of McGuire et al. in 1983, who demonstrated that transcutaneous stimulation of the common peroneal or posterior tibial nerve could alleviate lower urinary tract symptoms (LUTS), Professor Stoller introduced a refined percutaneous technique in 1990, termed Stoller Afferent Nerve Stimulation (SANS). This method specifically targets the posterior tibial nerve to treat overactive bladder (OAB) syndrome.

Clinical results from an early cohort of 90 patients showed that 80% experienced at least a 50% reduction in symptoms, establishing PTNS as a promising alternative to pharmacologic or more invasive therapies. Over time, PTNS has been successfully applied to various bladder conditions, including neurogenic bladder, non-obstructive urinary retention (NOUR), pediatric voiding dysfunction, and chronic pelvic pain/painful bladder syndrome (CPP/PBS).

A systematic review of published studies on PTNS reports broad effectiveness across patient populations:

  • 37–100% symptom improvement in OAB patients
  • 41–100% effectiveness in NOUR patients
  • Up to 100% response rate in CPP/PBS and pediatric dysfunction cases

These findings underscore PTNS as a safe, effective, and non-pharmacological option for bladder control, although additional research is needed to confirm its long-term efficacy and expand its indications.

Professor Stoller will also highlight Tensi+, a state-of-the-art device developed by Stimuli Technology. Tensi+ employs transcutaneous electrical nerve stimulation (TENS) to activate the posterior tibial nerve non-invasively. The device is designed for daily 20-minute treatments over a minimum of 12 weeks, with some patients experiencing symptom relief as early as six weeks. Clinical studies from Europe and Canada validate Tensi+ for its safety and efficacy, making it an accessible, patient-friendly solution for managing OAB and related voiding dysfunctions.

This presentation will provide insights into PTNS’s clinical development, treatment protocols, and emerging technologies like Tensi+, offering valuable knowledge for clinicians and researchers focused on improving bladder dysfunction management.