Opinion
Video
Review of Device-Based and Minimally-Invasive Approaches in OAB Treatment
In this insightful episode, Dr. Kennelly, along with Dr. Eilber and Dr. Benson, discuss the transition from pharmacologic treatments to third-line therapies for overactive bladder, focusing on the mechanism of action of various neuromodulation methods and benefits they offer to patients seeking sustainable solutions for OAB management.
Transcript:
Dr. Kennelly: And you both mentioned kind of these third-line therapies. And I know Dr. Eilber, you're talking about the AUA guidelines. Can you tell us in general, what if pharmacologic therapy has kind of met its need? What are third -line therapies?
Dr. Eilber: So third-line therapies include under a broad umbrella called neuromodulation, right? We traditionally have done peripheral sacral nerve stimulation which has been around since the late 90s. That is an implant and I think for the appropriate patient it works really well with the newer devices that are MRI compatible and longer battery life. I think it's especially a good option for younger patients, right? Because if it was my daughter or, you know, even myself, I wouldn't necessarily want to be on medications indefinitely. I'd want to have a one and done and stop, you know, checking with my doctor every six months or a year. And then we also have, you know, injection of Botox into the bladder. And I have no day to support this, but my personal belief is I think people who really have OAB dry, like I was talking about earlier especially if they don't. respond to anticholinergics. I think those are perfect candidates for neuromodulation. I think they have sensory urgency. And I think that people who leak, you can't just have sensory. You have to have some type of spasticity. I think that if you have even a modest response to medication, I don't necessarily do your dynamics on those patients. I would move them directly to doing bladder Botox. But if they have zero response, especially a mixed picture, I think it is in the patient's best interest that we study their bladder with urodynamics so that we can know exactly what we're treating because we're no longer just trying pills that are either reversible or we're talking about doing invasive procedures.
Dr Kennelly: Right, I think as stated prior to this, first line therapy, second line therapy, behavioral lifestyle changes, urge suppression, pharmacotherapy, that really is any provider has the ability to do that, meaning family practice, internal medicine, really anyone along that line. But it seems to be that moving on to advanced therapies, which would include sacroignal modulation, transcutaneous tibial nerve stimulation, posterior tibial nerve stimulation, and endovascular botulinum toxin, those are really dedicated to the more of the specialists, which would be urogynecology and urology. So I think that these therapies are, we have to embrace them because our other colleagues that are in primary care don't have the opportunity. So really, as specialists, we need to know about them.
Dr Kennelly: So Dr. Benson, can you give a little bit of background of, in general, if you put all the neuromodulations together, whether that be sacral, tibial, or posterior tibial nerve, what's the mechanism of action for that?
Dr. Benson: Sure. It's modulation of the sensory afferent fibers. And if we think of our bladder, I always tell patients your nervous system is what really allows you to take in the world and make appropriate decisions. And so those afferent fibers coming from the bladder are up-regulated, and they're sending essentially aberrant signals. And I describe it as noise. I describe it as static, as channeling. chatter, you know, whatever you might want to call it, or what I tell patients often it's like a telemarketer that keeps calling you and just frustrates you to the point where you act upon it.
And these afferent fibers then are essentially up regulating and changing the behavior of the bladder, essentially leading to more urge and frequency. And in general, a lot of these patients can kind of relate to that a little bit better. I always say, for instance, if you have diabetes, you might have neuropathy in your feet. If you have visual problems, you might not interpret things that you see as well, etc. But these nerve fibers are the communication cable. And if these communications are in error, then it's going to default for what you're having. And so we have a conversation about modulation of those of those nerve fibers. And you know, again, I think the simpler you keep that conversation probably the better for most, but most people do understand there's a communication, I always say it's like a phone call and you got the brain on one end and the bladder on the other and you have static in the call.
Dr Kennelly: I think from the standpoint of kind of the differences of neuromodulation, whether that's sacral, or tibial, or the transmission transcutaneous, is the mechanism still the same?
Dr. Benson: Well, it may not be, it may not be exactly the same, but I think when I explain it to a patient, I don't parcel it out too much, I kind of keep it at a pretty high level. And as we're trying to provide stimulation or modulation to these nerves to allow them to act in a more normal way. And indeed, you're right, probably the area of stimulation with tibial nerve stem, posterior tibial nerve stem versus sacral stem is probably different. And we do see some differential responses in the patient groups depending on the form of stem that's used.But in general, if you batch them all together, they're successful. And they're successful in a long-term simplistic manner that patients can get better and stay better. And that's really kind of how the message that we related the patient.
Dr Kennelly: Yeah, because I think you're stating earlier this OAB is really a chronic condition. And so to me it sounds like you're setting the foundation, the framework of something that is there and allowing this sort of a pacing technology to stimulate the atheric nerves. Would that be?
Right, you know, I just, I tell patients that this is something that can help you day in and day out. So as opposed to a medication which has a dose and has a finite life and it's gone, this is an ongoing existential therapy that will continue to work for you day in and day out. And that's what these patients are really looking for. Many of them have dealt with this for years before they're in and they understand that they need a long -term solution.
And so these have more durability. We point to a lot of the data looking at patients that have used these long -term and their success. We've also looked at how, you know, they need to come in and do things.
And that's the other part of this that patients really want. They don't want to be in seeing you all the time. They want to be living their life. And what I find that taking medications does is reminds them of their problem every single day. So every time they open that bottle and deal with the side effects or have to go pick it up, they're then burdened back by the problem that brought them in and they want freedom from that. And that's what these really offer.
*Video transcript is AI-generated and reviewed by Urology Times® editorial staff.
