The Dawn of Bladder Hyperactivity Disorder

        Bladder overactivity is a common disease in urology clinics, and its incidence increases with age. Some elderly patients are afraid to go out, reduce social activities, and even feel depressed because of this. But as long as we prescribe the right medicine, we can still significantly improve our quality of life. This issue of 'Health Column' introduces a new adjuvant therapy - percutaneous tibial nerve stimulation (PTNS), which helps patients overcome their difficulties.

                Have you encountered a similar situation before?

        Mr. Zhang walked into the urology clinic and complained that he often felt the urge to urinate. Sometimes, shortly after using the restroom, he wanted to go back, but the urine output was not high. After examination, there was no infection in the urine, and there was no residual urine in the bladder after urination. The diagnosis was bladder overactivity, so oral medication was prescribed for treatment.

        After taking the medication for a month, Mr. Zhang's urgency to urinate decreased. However, due to side effects such as dry mouth and tongue, as well as difficulty in defecation, he stopped taking the medication on his own after taking it for two weeks. Although he changed to a new medication during the follow-up visit, the symptoms of dry mouth still did not improve, causing him great distress.

        Some patients may also have the same feelings as Mr. Zhang and refuse to take medication, in which case "percutaneous tibial nerve stimulation (PTNS)" is a good adjuvant therapy.

        The principle of percutaneous tibial nerve electrical stimulation surgery

        The human body regulates urine storage and urination functions through the coordinated action of fine nerves and muscles. When storing urine, as the amount of urine increases, the receptors on the bladder wall are pulled, and their neural signals are transmitted to the spinal cord through the pelvic nerves. After the sympathetic nerves in the spinal cord are activated, the signals are transmitted to the adrenaline receptors on the bladder wall through the lower abdominal nerves, causing the bladder wall to relax and store urine. The perineal nerve can control the external sphincter muscle to maintain contraction and avoid urinary leakage.

        When urinating, the bladder wall transmits the signal of bladder inflation to the urinary center of the pons, triggering the urinary reflex, causing the parasympathetic nervous system to release cholinergic receptors on the bladder wall, contract the bladder, and trigger urination. At the same time, the cerebral cortex sends signals to suppress the perineal nerve, causing the external sphincter muscle to relax and urinate. The entire regulation process is quite complex, in which both the parasympathetic nervous system and the body nerve that controls the sphincter muscle innervate the bladder through the S2-S4 nerve of the crest vertebrae. Therefore, the S2-S4 nerve plays an important role in urination and urine storage.

        The tibial nerve originates from the crest nerve of L4-S3 and is a branch of the sciatic nerve located on the inner side of the calf, closely connected to the nerves in the bladder and pelvic region. Percutaneous tibial nerve electrical stimulation is a technique that uses weak electrical currents to stimulate the posterior tibial nerve, affecting the neural regulation of the bladder and improving symptoms such as bladder hyperactivity.

        Indications and treatment steps of percutaneous tibial nerve electrical stimulation surgery

        Whether it is bladder hyperactivity or patients with acute urinary symptoms combined with urinary incontinence, percutaneous tibial nerve stimulation can be used for treatment. However, if the device is equipped with a heart rhythm generator, has bleeding tendencies such as coagulation dysfunction, peripheral nerve damage, or is pregnant, it is considered a contraindication and should be discussed with a physician to seek alternative treatment options.

        The treatment process of percutaneous tibial nerve stimulation is not complicated. Firstly, after the physician confirms that the patient has no contraindications through consultation and evaluation, an appointment can be made for treatment in the urology outpatient area. During treatment, the patient lies on the diagnosis and treatment bed, and the physician applies an injection after disinfecting with alcohol swabs at a distance of 4-5 cm above the medial ankle of the patient's calf, where the tibial nerve passes through. The needle is a solid needle for acupuncture and moxibustion. The needle body is small and the front end is blunt, so it will not cause tissue damage.

        Next, the physician will clamp the needle with an electrode wire and connect the other end of the wire to the machine to form an electrical circuit. Then, the power will be turned on and a power test will be conducted to confirm that the needle insertion electrode position correctly reflects the tibial nerve. After adjusting the intensity of the electrical stimulation, the formal treatment will begin for 30 minutes, and finally remove the needle to complete one session of treatment. The complete treatment course lasts for 12 weeks, with treatment given once a week. If strengthening is needed, you can discuss the frequency of subsequent treatment with the physician.

        The efficacy and precautions of percutaneous tibial nerve electrical stimulation surgery

        According to the treatment guidelines provided by the European Society of Urology, a randomized controlled trial (RCT) study showed that compared to oral anticholinergic drugs, percutaneous tibial nerve stimulation is more effective in reducing the frequency of urgent urinary incontinence in patients; As for other indicators of bladder hyperactivity such as urgency and frequent urination, their therapeutic effects are comparable. In addition, three other studies compared this treatment method with sham treatment and the anticholinergic drug tolterodine, and tracked maintenance treatment for 3 years. The results all confirmed that this surgery can sustainably and equivalently improve bladder movement symptoms as oral medication, demonstrating its efficacy comparable to current standard oral medications.

        Although the treatment of "percutaneous tibial nerve stimulation" is relatively simple, it should still be noted that in case of pregnancy or implantation of a pacemaker, the doctor should be actively informed, and the local skin should be kept clean to avoid local application of lotion and other items before treatment, so as to reduce the risk of infection. In addition, after treatment, it is necessary to drink moderate amounts of water, reduce the intake of coffee and other stimulating beverages, and also combine pelvic muscle training (such as Kegel exercises) to enhance the therapeutic effect.

        Conclusion

        Percutaneous tibial nerve stimulation is a safe, effective, and minimally invasive treatment option, particularly suitable for patients with bladder hyperactivity, urgency urinary incontinence, or other lower urinary tract symptoms. Although the treatment itself is relatively safe, each patient's condition is different. It is recommended to have a thorough discussion with the physician first, establish reasonable treatment expectations, and accept the treatment with peace of mind under professional guidance.

        Dr. Li Honggeng's expertise includes: urinary disorders, urinary incontinence, prostate enlargement and laser surgery, prostate steam thermal ablation surgery, and treatment of prostate inflammation; Urinary tract stones (minimally invasive flexible ureteroscopy surgery); Minimally invasive hernia surgery, da Vinci hernia surgery, foreskin gun and ligation surgery. More information: https://www.femh.org.tw/section/sectionDetail2.aspx?CID=0285&DoctorID=92022

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