Electric Stimulation for Overactive Bladder: Patient Evaluation, Device Selection & Complications

[Dr. Daniel Hoffman]
Well, again, you know, I like the patients in retention for neurostimulation. I think the patients in nonobstructive retention do really well. but for me again, it's all about what the patient wants. And once you start talking about neurostimulation and how it works, most patients tend to select that pathway.

I think that when you talk about a staged approach where you can actually take the therapy out on a test drive and get a sense of whether it works for you or not, before you have to make a commitment to that therapy. I think a lot of people buy into that. And at least in my practice, I do a lot of percutaneous nerve evaluations.

So you come in for a 15 to 20 minute procedure, you wear the device for three to five days, and then you can make a decision as to whether that's right for you or not. And if it's not right for you, then we can talk about Botox or tibial nerve modulation. But I think tibial nerve modulation and sacral neuromodulation are flip sides of the same coin.

[Dr. Jose Silva]
So for a patient that has a Foley catheter, are you doing a PNE or are you doing a stage one for those patients?

[Dr. Daniel Hoffman]
If they're catheter dependent, then we have to get them out of that state. So I learned that one the hard way too. You either need to put a suprapubic tube in them or you need to teach them CIC. If they're in retention, I'll go in, I'll put it in, and if they refuse to learn catheterization, I'll put a suprapubic tube in and then I'll do a stage approach for that patient in particular. Because when they're in chronic retention like that, it takes them a little longer for the bladder to get going. It's not going to be that three-to-five day PNE that's going to jumpstart their bladder.

So for that patient, a staged approach is often a little better, but for your frequency urgency, and I don't know if you see it in your practice, but my overactive bladder patients are coming in younger and younger. And those patients do really well with neuromodulation because they understand that it's a device, it's something they can control. It's something they can recharge, and it puts them in the driver's seat of their symptoms.

[Dr. Jose Silva]
Let's talk about some complications. Some patients complain of chronic pain, chronic pain down the leg. Do you try to replace the device, or what do you do with those patients?

[Dr. Daniel Hoffman]
If they're having pain down the leg, the first thing I do is reprogram. I try to get the arc of the energy, as far away from S4 as possible. So you try to bring it up closer to S3. And usually if you're getting referred pain down the leg, it's because you're getting closer to four. The patient that doesn't do well with a reprogram, I would consider lead revision and I’m not hesitant to do a lead revision on a patient. I think that the patient that has pain at the stimulator site can be a little bit more challenging. Sometimes you have to do battery revisions or with generator revisions, get it a little deeper if it's too superficial…

[Dr. Jose Silva]
Have you used the recharger of the Medtronic device?

[Dr. Daniel Hoffman]
I have, and I've had some patients come in with a dead primary cell and they want to upgrade to a rechargeable device or an MRI compatible device. And do they want to stick with Medtronic? And we absolutely go down that pathway.

[Dr. Jose Silva]
You don't need to change the lead, right. I mean, as long as the lead was MRI compatible.

[Dr. Daniel Hoffman]
That's the catch, right? So the primary cell is where the things that were not MRI compatible were, the lead was MRI compatible, but the lead is not interchangeable. So if you're going to go from primary cell to rechargeability, you've got to do a full swap. If you're just going to put in an MRI compliant primary cell, you can keep the same lead.