Neuromodulation Therapies for Urinary Incontinence
Neuromodulation therapies use electrical stimulation to change the nerve signals involved in bladder and bowel control. They can be highly effective for patients who haven’t improved with more conservative approaches like lifestyle changes, pelvic floor physical therapy, or medications. In current guidelines, neuromodulation sits among the third-line options for overactive bladder, considered after behavioral therapy and medications, though not every patient has to move through each step in a fixed order. There are three main types of neuromodulation used for urinary incontinence:
1. Sacral Neuromodulation (SNM)
Sacral neuromodulation involves implanting a small device that sends mild electrical pulses to the sacral nerves, which control bladder and bowel function.
Key Features:
- Minimally invasive surgical procedure
- Long-term therapy with implanted device
- Effective for both urinary and fecal incontinence
- Allows for a trial period before permanent implantation
Available Systems:
- Medtronic InterStim™ System
- Axonics® Sacral Neuromodulation System
I implant both systems. Both now offer rechargeable and non-rechargeable batteries. A non-rechargeable device often lasts 10 to 15 years before it needs to be replaced, depending on your settings. Rechargeable models are designed to last 15 years or more.
Sacral neuromodulation can make a big difference for patients with refractory overactive bladder or urge incontinence. A major advantage is that you can test the therapy before committing to the implant.
2. Percutaneous Tibial Nerve Stimulation (PTNS)
PTNS is a non-surgical, office-based treatment that stimulates the tibial nerve near the ankle to improve bladder control.
Key Features:
- No surgery required
- Typically involves 12 weekly 30-minute sessions performed in the office, followed by maintenance treatments
- Can be effective for overactive bladder and urge incontinence
- Minimal side effects, low risk.
Available Systems:
- Medtronic NURO™ System
- Laborie Urgent® PC
PTNS is a good option if you want to try neuromodulation without surgery. The weekly sessions take time, but many patients get significant relief with minimal risk. I don’t offer PTNS in my office. For patients who want tibial nerve stimulation, I offer the implanted version below, which delivers the same kind of stimulation without the weekly visits.
3. Implanted Tibial Nerve Stimulation
This newer form of neuromodulation involves a small implanted device that stimulates the tibial nerve. It gives you long-term therapy without weekly office visits.
Key Features:
- Small implant placed through an incision near the inner ankle, under local anesthetic
- Provides ongoing stimulation without frequent office visits
- FDA approved for urge urinary incontinence
- No test phase before the implant, unlike sacral neuromodulation
Available Systems:
- Medtronic Altaviva™, which I use. It’s rechargeable, needs a charge only once or twice a year, and runs on its own schedule.
- Valencia Technologies eCoin®, which isn’t rechargeable and is expected to last about 3 years
- BlueWind Revi™, which is powered by a wearable unit you put on for each session
Implanted tibial nerve stimulation sits between PTNS and sacral neuromodulation. It provides ongoing therapy like SNM, with a smaller procedure at the ankle.
In the TITAN 2 trial behind Altaviva’s approval, 61% of patients had at least half as many urge leaks at 12 months, and 22% had none. The eCoin and Revi trials reported higher response rates. Those trials enrolled different patients, and TITAN 2’s were older and heavier on average, so the numbers can’t be compared head to head. More on the procedure, results, and side effects: Altaviva tibial nerve implant.
Choosing the Right Neuromodulation Therapy
Which therapy fits you depends on several things, including:
- Severity and type of incontinence
- Patient preferences regarding surgery and ongoing management
- Response to previous treatments
- Overall health and medical history
We’ll work together to decide which neuromodulation approach, if any, fits your situation. Each one has trade-offs, and what works best varies from patient to patient.
Neuromodulation usually comes after more conservative treatments haven’t worked well enough. For many patients who have struggled with bladder control, it can finally bring relief.
References
- Lightner DJ, Gomelsky A, Souter L, et al. Diagnosis and Treatment of Overactive Bladder (Non-Neurogenic) in Adults: AUA/SUFU Guideline Amendment 2019. The Journal of Urology. 2019. doi:10.1097/JU.0000000000000309
- Goldman HB, Lloyd JC, Noblett KL, et al. International Continence Society best practice statement for use of sacral neuromodulation. Neurourology and Urodynamics. 2018. doi:10.1002/nau.23596
- Committee on Practice Bulletins—Gynecology, American Urogynecologic Society. Urinary Incontinence in Women (ACOG Practice Bulletin No. 155). Obstetrics & Gynecology. 2015. doi:10.1097/AOG.0000000000001148
- Amundsen CL, Richter HE, Menefee SA, et al. OnabotulinumtoxinA vs Sacral Neuromodulation on Refractory Urgency Urinary Incontinence in Women: A Randomized Clinical Trial. JAMA. 2016. doi:10.1001/jama.2016.14617
- Peters KM, Carrico DJ, Perez-Marrero RA, et al. Randomized Trial of Percutaneous Tibial Nerve Stimulation Versus Sham Efficacy in the Treatment of Overactive Bladder Syndrome: Results From the SUmiT Trial. The Journal of Urology. 2010. doi:10.1016/j.juro.2009.12.036
- Peters KM, Carrico DJ, Wooldridge LS, et al. Percutaneous Tibial Nerve Stimulation for the Long-Term Treatment of Overactive Bladder: 3-Year Results of the STEP Study. The Journal of Urology. 2013. doi:10.1016/j.juro.2012.11.175
- Lukacz ES, Santiago-Lastra Y, Albo ME, et al. Urinary Incontinence in Women: A Review. JAMA. 2017. doi:10.1001/jama.2017.12137
- Meyer I, Richter HE. Accidental Bowel Leakage/Fecal Incontinence: Evidence-Based Management. Obstetrics and Gynecology Clinics of North America. 2021. doi:10.1016/j.ogc.2021.05.003
- Lee U, Xavier K, Carey J, et al. Implantable Tibial Neuromodulation Therapy Improves Symptoms of Urge Urinary Incontinence From the TITAN 2 Pivotal Study. The Journal of Urology. 2026. doi:10.1097/JU.0000000000004958