Skip to main content

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

  • Review Article
  • Published:

Neuromodulation for overactive bladder

Abstract

Overactive bladder (OAB) affects millions of people worldwide yet first-line treatments are often poorly tolerated and compliance rates are low. Neuromodulation works via afferent nerve modulation and offers a minimally invasive and reversible alternative treatment option for patients with OAB who have failed first-line therapy. Neuromodulation has revolutionized the management of OAB and is now well established as a safe and effective treatment for those refractory to conservative treatments. Multiple neuroanatomical pathways have been described for sacral neuromodulation including the S3 nerve root, pudendal nerve and tibial nerve. The S3 nerve root is currently the main treatment target and has the most long-term data on safety and efficacy to support its use. However, studies on neuromodulation at the pudendal nerve or posterior tibial nerve have been positive and their role in treatment continues to evolve. Most urologists who are experienced in voiding dysfunction can become proficient in each technique. Patient selection, surgical techniques and postoperative management differ slightly between approaches and urologists should familiarize themselves with these differences. Treatment of OAB should progress from the least to most invasive modality, and neuromodulation provides an attractive option owing to its minimally invasive approach, tolerability, positive outcomes and reversibility.

Key Points

  • Overactive bladder (OAB) is defined by the International Continence Society (ICS) as a syndrome characterized by urgency, with or without urgency incontinence, usually with frequency and nocturia

  • Initial treatment options for OAB include behavioural modification, pharmacotherapy and physical therapy, either as monotherapies or in combination

  • Neuromodulation is hypothesized to relieve OAB symptoms by modifying somatic afferent sensory processing in the sacral spinal cord

  • Sacral, tibial or pudendal nerves can be targeted by neuromodulation with specific indications and techniques for each

  • Treatment of OAB should progress from the least to most invasive modality, and neuromodulation provides an attractive option owing to its minimally invasive approach, tolerability, positive outcomes and reversibility

This is a preview of subscription content, access via your institution

Access options

Rent or buy this article

Prices vary by article type

from$1.95

to$39.95

Prices may be subject to local taxes which are calculated during checkout

Figure 1: Sacral neuromodulation—first-stage lead placement.
Figure 2: Pudendal nerve stimulation.
Figure 3: Percutaneous tibial nerve stimulation.

Similar content being viewed by others

References

  1. Abrams, P. et al. Fourth International Consultation on Incontinence Recommendations of the International Scientific Committee: Evaluation and treatment of urinary incontinence, pelvic organ prolapse, and fecal incontinence. Neurourol. Urodyn. 29, 213–240 (2010).

    Article  CAS  PubMed  Google Scholar 

  2. Haylen, B. T. et al. An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for female pelvic floor dysfunction. Int. Urogynecol. J. 21, 5–26 (2010).

    Article  PubMed  Google Scholar 

  3. Stewart, W. F. et al. Prevalence and burden of overactive bladder in the United States. World J. Urol. 20, 327–336 (2003).

    CAS  PubMed  Google Scholar 

  4. Irwin, D. E. et al. Population-based survey of urinary incontinence, overactive bladder, and other lower urinary tract symptoms in five countries: results of the EPIC study. Eur. Urol. 50, 1306–1314 (2006).

    Article  PubMed  Google Scholar 

  5. Milsom, I. et al. How widespread are the symptoms of an overactive bladder and how are they managed? A population-based prevalence study. BJU Int. 87, 760–766 (2001).

    Article  CAS  PubMed  Google Scholar 

  6. Coyne, K. S. et al. National community prevalence of overactive bladder in the United States stratified by sex and age. Urology 77, 1081–1087 (2011).

    Article  PubMed  Google Scholar 

  7. Irwin, D. E., Kopp, Z. S., Agatep, B., Milsom, I. & Abrams, P. Worldwide prevalence estimates of lower urinary tract symptoms, overactive bladder, urinary incontinence and bladder outlet obstruction. BJU Int. 108, 1132–1138 (2011).

    Article  PubMed  Google Scholar 

  8. Irwin, D. E. et al. The economic impact of overactive bladder syndrome in six Western countries. BJU Int. 103, 202–209 (2009).

    Article  PubMed  Google Scholar 

  9. Sexton, C. C. et al. Impact of overactive bladder on work productivity in the United States: results from EpiLUTS. Am. J. Manag. Care 15, S98–S107 (2009).

    PubMed  Google Scholar 

  10. Coyne, K. S. et al. The impact of overactive bladder, incontinence and other lower urinary tract symptoms on quality of life, work productivity, sexuality and emotional well-being in men and women: results from the EPIC study. BJU Int. 101, 1388–1395 (2008).

    Article  PubMed  Google Scholar 

  11. Coyne, K. S., Margolis, M. K., Kopp, Z. S. & Kaplan, S. A. Racial differences in the prevalence of overactive bladder in the United States from the epidemiology of LUTS (EpiLUTS) study. Urology 79, 95–101 (2012).

    Article  PubMed  Google Scholar 

  12. Liu, R. T. et al. Prevalence of overactive bladder and associated risk factors in 1359 patients with type 2 diabetes. Urology 78, 1040–1045 (2011).

    Article  PubMed  Google Scholar 

  13. Link, C. L., Steers, W. D., Kusek, J. W. & McKinlay, J. B. The association of adiposity and overactive bladder appears to differ by gender: results from the Boston Area Community Health survey. J. Urol. 185, 955–963 (2011).

    Article  PubMed  PubMed Central  Google Scholar 

  14. Wood, K. L., Folkerts, D., Finstrom, K. & Newman, C. Overactive bladder and urinary incontinence: A multitherapy approach to treatment. Sex. Reprod. Menopause 4, 66–70 (2006).

    Article  Google Scholar 

  15. Klutke, C. G. et al. Combined effects of behavioral intervention and tolterodine in patients dissatisfied with overactive bladder medication. J. Urol. 181, 2599–2607 (2009).

    Article  PubMed  Google Scholar 

  16. Stav, K. & Dwyer, P. L. Urinary bladder stones in women. Obstet. Gynecol. Surv. 67, 715–725 (2012).

    Article  PubMed  Google Scholar 

  17. Hanno, P. M. et al. AUA guideline for the diagnosis and treatment of interstitial cystitis/bladder pain syndrome. J. Urol. 185, 2162–2170 (2011).

    Article  PubMed  Google Scholar 

  18. Peters, K. M. & Carrico, D. J. Frequency, urgency, and pelvic pain: treating the pelvic floor versus the epithelium. Curr. Urol. Rep. 7, 450–455 (2006).

    Article  PubMed  Google Scholar 

  19. Gormley, E. A. et al. Diagnosis and treatment of overactive bladder (non-neurogenic) in adults: AUA/SUFU guideline. J. Urol. 188 (Suppl. 6), 2455–2463 (2012).

    Article  PubMed  Google Scholar 

  20. Dallosso, H. M., McGrother, C. W., Matthews, R. J. & Donaldson, M. M. The association of diet and other lifestyle factors with overactive bladder and stress incontinence: a longitudinal study in women. BJU Int. 92, 69–77 (2003).

    Article  CAS  PubMed  Google Scholar 

  21. Lee, J. G., Wein., A. J. & Levin, R. M. The effect of caffeine on the contractile response of the rabbit urinary bladder to field stimulation. Gen. Pharmacol. 24, 1007–1011 (1993).

    Article  CAS  PubMed  Google Scholar 

  22. Burgio, K. L. Influence of behavior modification on overactive bladder. Urology 60, 72–76 (2002).

    Article  PubMed  Google Scholar 

  23. Godec, C. J. “Timed voiding”–a useful tool in the treatment of urinary incontinence. Urology 23, 97–100 (1984).

    Article  CAS  PubMed  Google Scholar 

  24. Burgio, K. L. et al. Behavioral training with and without biofeedback in the treatment of urge incontinence in older women: a randomized controlled trial. JAMA 288, 2293–2299 (2002).

    Article  PubMed  Google Scholar 

  25. Smith, A. L. & Wein, A. J. Recent advances in the development of antimuscarinic agents for overactive bladder. Trends Pharmacol. Sci. 31, 470–475 (2010).

    Article  CAS  PubMed  Google Scholar 

  26. Madhuvrata, P., Cody, J. D., Ellis, G., Herbison, G. P. & Hay-Smith, E. J. Which anticholinergic drug for overactive bladder symptoms in adults. Cochrane Database Syst. Rev. 1, CD005429 (2012).

    PubMed  Google Scholar 

  27. Chapple, C. R. et al. Randomized double-blind, active-controlled phase 3 study to assess 12-month safety and efficacy of mirabegron, a β(3)-adrenoceptor agonist, in overactive bladder. Eur. Urol. 63, 296–305 (2012).

    Article  PubMed  CAS  Google Scholar 

  28. Nitti, V. et al. Results of a randomized phase III trial of mirabegron in patients with overactive bladder. J. Urol. 189, 1388–1395 (2012).

    Article  PubMed  CAS  Google Scholar 

  29. Yu, Y. F., Nichol, M. B., Yu, A. P. & Ahn, J. Persistence and adherence of medications for chronic overactive bladder/urinary incontinence in the california medicaid program. Value Health 8, 495–505 (2005).

    Article  PubMed  Google Scholar 

  30. Dmochowski, R. R. & Newman, D. K. Impact of overactive bladder on women in the United States: results of a national survey. Curr. Med. Res. Opin. 23, 65–76 (2007).

    Article  PubMed  Google Scholar 

  31. Benner, J. S. et al. Patient-reported reasons for discontinuing overactive bladder medication. BJU Int. 105, 1276–1282 (2010).

    Article  PubMed  Google Scholar 

  32. Wagg, A., Compion, G., Fahey, A. & Siddiqui, E. Persistence with prescribed antimuscarinic therapy for overactive bladder: a UK experience. BJU Int. 110, 1767–1774 (2012).

    Article  CAS  PubMed  Google Scholar 

  33. Leng, W. W. & Chancellor, M. B. How sacral nerve stimulation neuromodulation works. Urol. Clin. North Am. 32, 11–18 (2005).

    Article  PubMed  Google Scholar 

  34. Langley, J. N. & Anderdon, H. K. The innervations of the pelvic and adjoining viscera. II. The bladder. J. Physiol. 19, 71–84 (1895).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  35. Hald, T., Agrawal, G. & Kantrowitz, A. Studies in stimulation of the bladder and its motor nerves. Surgery 60, 848–856 (1966).

    CAS  PubMed  Google Scholar 

  36. Heine, J. P., Schmidt, R. A. & Tanagho, E. A. Intraspinal sacral root stimulation for controlled micturition. Invest. Urol. 15, 78–82 (1977).

    CAS  PubMed  Google Scholar 

  37. Brindley, G. S. Emptying the bladder by stimulating sacral ventral roots. J. Physiol. 237, 15P–16P (1974).

    Article  CAS  PubMed  Google Scholar 

  38. Tanagho, E. A. & Schmidt, R. A. Bladder pacemaker: scientific basis and clinical future. Urology 20, 614–619 (1982).

    Article  CAS  PubMed  Google Scholar 

  39. Juenemann, K. P., Lue, T. F., Schmidt, R. A. & Tanagho, E. A. Clinical significance of sacral and pudendal nerve anatomy. J. Urol. 139, 74–80 (1988).

    Article  CAS  PubMed  Google Scholar 

  40. Tanagho, E. A. & Schmidt, R. A. Electrical stimulation in the clinical management of the neurogenic bladder. J. Urol. 140, 1331–1339 (1988).

    Article  CAS  PubMed  Google Scholar 

  41. South, M. M., Romero, A. A., Jamison, M. G., Webster, G. D. & Amundsen, C. L. Detrusor overactivity does not predict outcome of sacral neuromodulation test stimulation. Int. Urogynecol. J. Pelvic Floor Dysfunct. 18, 1395–1398 (2007).

    Article  PubMed  Google Scholar 

  42. Groenendijk, P. M. et al. Urodynamic evaluation of sacral neuromodulation for urge urinary incontinence. BJU Int. 101, 325–329 (2008).

    Article  PubMed  Google Scholar 

  43. Kessler, T. M. et al. Sacral neuromodulation for neurogenic lower urinary tract dysfunction: systematic review and meta-analysis. Eur. Urol. 58, 865–874 (2010).

    Article  PubMed  Google Scholar 

  44. Levin, P. J., Wu, J. M., Siddiqui, N. Y. & Amundsen, C. L. Does obesity impact the success of an InterStim test phase for the treatment of refractory urge urinary incontinence in female patients? Female Pelvic Med. Reconstr. Surg. 18, 243–246 (2012).

    Article  PubMed  Google Scholar 

  45. Amundsen, C. L., Romero, A. A., Jamison, M. G. & Webster, G. D. Sacral neuromodulation for intractable urge incontinence: are there factors associated with cure? Urology 66, 746–750 (2005).

    Article  PubMed  Google Scholar 

  46. Chermansky, C. J., Krlin, R. M., Holley, T. D., Woo, H. H. & Winters, J. C. Magnetic resonance imaging following InterStim®: an institutional experience with imaging safety and patient satisfaction. Neurourol. Urodyn. 30, 1486–1488 (2011).

    Article  PubMed  Google Scholar 

  47. Faucheron, J. L., Voirin, D. & Badic, B. Sacral nerve stimulation for fecal incontinence: causes of surgical revision from a series of 87 consecutive patients operated on in a single institution. Dis. Colon Rectum 53, 1501–1507 (2010).

    Article  PubMed  Google Scholar 

  48. Elkelini, M. S. & Hassouna, M. M. Safety of MRI at 1.5Tesla in patients with implanted sacral nerve neurostimulator. Eur. Urol. 50, 311–316 (2006).

    Article  PubMed  Google Scholar 

  49. Medtronic. MRI Guidelines for InterStimTherapy neurostimulation systems [online], (2012).

  50. Baxter, C. & Kim, J. H. Contrasting the percutaneous nerve evaluation versus staged implantation in sacral neuromodulation. Curr. Urol. Rep. 11, 310–314 (2010).

    Article  PubMed  PubMed Central  Google Scholar 

  51. Vasavada, S. & Rackley, R. in Campbell-Walsh Urology 10th edn (eds Wein, A. J., Kavoussi, L. K., Novick, A. C., Partin, A. W. & Peters, C. A.) 2026–2046 (Elsevier Saunders, 2011).

    Google Scholar 

  52. Peters, K. M. Neuromodulation, staged intervention, and new instruments. Atlas Urol. Clinics North Am. 12, 275–291 (2004).

    Article  Google Scholar 

  53. Peters, K. M., Killinger, K. A. & Boura, J. A. Is sensory testing during lead placement crucial for achieving positive outcomes after sacral neuromodulation? Neurourol. Urodyn. 30, 1489–1492 (2011).

    Article  PubMed  Google Scholar 

  54. Spinelli, M. et al. New sacral neuromodulation lead for percutaneous implantation using local anesthesia: description and first experience. J. Urol. 170, 1905–1907 (2003).

    Article  PubMed  Google Scholar 

  55. Siegel, S. W. et al. Long-term results of a multicenter study on sacral nerve stimulation for treatment of urinary urge incontinence, urgency-frequency, and retention. Urology 56, 87–91 (2000).

    Article  CAS  PubMed  Google Scholar 

  56. Sherman, N. D., Jamison, M. G., Webster, G. D. & Amundsen, C. L. Sacral neuromodulation for the treatment of refractory urinary urge incontinence after stress incontinence surgery. Am. J. Obstet. Gynecol. 193, 2083–2087 (2005).

    Article  PubMed  Google Scholar 

  57. Peters, K. M., Killinger, K. A., Boguslawski, B. M. & Boura, J. A. Chronic pudendal neuromodulation: expanding available treatment options for refractory urologic symptoms. Neurourol. Urodyn. 29, 1267–1271 (2010).

    Article  PubMed  Google Scholar 

  58. Borawski, K. M., Foster, R. T., Webster, G. D. & Amundsen, C. L. Predicting implantation with a neuromodulator using two different test stimulation techniques: A prospective randomized study in urge incontinent women. Neurourol. Urodyn. 26, 14–18 (2007).

    Article  PubMed  Google Scholar 

  59. Carey, M., Fynes, M., Murray, C. & Maher, C. Sacral nerve root stimulation for lower urinary tract dysfunction: overcoming the problem of lead migration. BJU Int. 87, 15–18 (2001).

    Article  CAS  PubMed  Google Scholar 

  60. Everaert, K. et al. A prospective randomized trial comparing the 1-stage with the 2-stage implantation of a pulse generator in patients with pelvic floor dysfunction selected for sacral nerve stimulation. Eur. Urol. 45, 649–654 (2004).

    Article  CAS  PubMed  Google Scholar 

  61. Leong, R. K., De Wachter, S. G., Nieman, F. H., de Bie, R. A. & van Kerrebroeck, P. E. PNE versus 1st stage tined lead procedure: a direct comparison to select the most sensitive test method to identify patients suitable for sacral neuromodulation therapy. Neurourol. Urodyn. 30, 1249–1252 (2011).

    PubMed  Google Scholar 

  62. Sutherland, S. E. et al. Sacral nerve stimulation for voiding dysfunction: One institution's 11-year experience. Neurourol. Urodyn. 26, 19–28 (2007).

    Article  PubMed  Google Scholar 

  63. Hassouna, M. M. et al. Sacral neuromodulation in the treatment of urgency-frequency symptoms: a multicenter study on efficacy and safety. J. Urol. 163, 1849–1854 (2000).

    Article  CAS  PubMed  Google Scholar 

  64. Latini, J. M., Alipour, M. & Kreder, K. J. Jr. Efficacy of sacral neuromodulation for symptomatic treatment of refractory urinary urge incontinence. Urology 67, 550–553 (2006).

    Article  PubMed  Google Scholar 

  65. van Kerrebroeck, P. E. et al. Results of sacral neuromodulation therapy for urinary voiding dysfunction: outcomes of a prospective, worldwide clinical study. J. Urol. 178, 2029–2034 (2007).

    Article  PubMed  Google Scholar 

  66. Bosch, J. L. & Groen, J. Sacral nerve neuromodulation in the treatment of patients with refractory motor urge incontinence: long-term results of a prospective longitudinal study. J. Urol. 163, 1219–1222 (2000).

    Article  CAS  PubMed  Google Scholar 

  67. Al-zahrani, A. A., Elzayat, E. A. & Gajewski, J. B. Long-term outcome and surgical interventions after sacral neuromodulation implant for lower urinary tract symptoms: 14-year experience at 1 center. J. Urol. 185, 981–986 (2011).

    Article  PubMed  Google Scholar 

  68. Groen, J., Blok, B. F. & Bosch, J. L. Sacral neuromodulation as treatment for refractory idiopathic urge urinary incontinence: 5-year results of a longitudinal study in 60 women. J. Urol. 186, 954–959 (2011).

    Article  PubMed  Google Scholar 

  69. Hijaz, A. & Vasavada, S. Complications and troubleshooting of sacral neuromodulation therapy. Urol. Clin. North Am. 32, 65–69 (2005).

    Article  PubMed  Google Scholar 

  70. Blandon, R. E., Gebhart, J. B., Lightner, D. J. & Klingele, C. J. Re-operation rates after permanent sacral nerve stimulation for refractory voiding dysfunction in women. BJU Int. 101, 1119–1123 (2008).

    Article  PubMed  Google Scholar 

  71. White, W. M., Mobley, J. D. 3rd, Doggweiler, R., Dobmeyer-Dittrich, C. & Klein, F. A. Incidence and predictors of complications with sacral neuromodulation. Urology 73, 731–735 (2009).

    Article  PubMed  Google Scholar 

  72. Gaynor-Krupnick, D. M., Dwyer, N. T., Rittenmeyer, H. & Kreder, K. J. Evaluation and management of malfunctioning sacral neuromodulator. Urology 67, 246–249 (2006).

    Article  PubMed  Google Scholar 

  73. Huang, J. C., Deletis, V., Vodusek, D. B. & Abbott, R. Preservation of pudendal afferents in sacral rhizotomies. Neurosurgery 41, 411–415 (1997).

    Article  CAS  PubMed  Google Scholar 

  74. Spinelli, M. et al. A new minimally invasive procedure for pudendal nerve stimulation to treat neurogenic bladder: description of the method and preliminary data. Neurourol. Urodyn. 24, 305–309 (2005).

    Article  PubMed  Google Scholar 

  75. Peters, K. M., Feber, K. M. & Bennett, R. C. Sacral versus pudendal nerve stimulation for voiding dysfunction: a prospective, single-blinded, randomized, crossover trial. Neurourol. Urodyn. 24, 643–647 (2005).

    Article  PubMed  Google Scholar 

  76. Peters, K. M. et al. Sustained therapeutic effects of percutaneous tibial nerve stimulation: 24-month results of the STEP study. Neurourol. Urodyn. 32, 24–29 (2012).

    Article  PubMed  Google Scholar 

  77. Amarenco, G. et al. Urodynamic effect of acute transcutaneous posterior tibial nerve stimulation in overactive bladder. J. Urol. 169, 2210–2215 (2003).

    Article  CAS  PubMed  Google Scholar 

  78. Peters, K. M. et al. Randomized trial of percutaneous tibial nerve stimulation versus Sham efficacy in the treatment of overactive bladder syndrome: results from the SUmiT trial. J. Urol. 183, 1438–1443 (2010).

    Article  PubMed  Google Scholar 

  79. Wooldridge, L. S. Percutaneous tibial nerve stimulation for the treatment of urinary frequency, urinary urgency, and urge incontinence: results from a community-based clinic. Urol. Nurs. 29, 177–185 (2009).

    PubMed  Google Scholar 

  80. Zinkgraf, K., Quinn, A. O., Ketterhagen, D., Kreuziger, B. & Stevenson, K. Percutaneous tibial nerve stimulation for treatment of overactive bladder and urinary retention in an elderly population. Urol. Nurs. 29, 30–34 (2009).

    PubMed  Google Scholar 

  81. Peters, K. M. et al. Randomized trial of percutaneous tibial nerve stimulation versus extended-release tolterodine: results from the overactive bladder innovative therapy trial. J. Urol. 182, 1055–1061 (2009).

    Article  CAS  PubMed  Google Scholar 

  82. MacDiarmid, S. A. et al. Long-term durability of percutaneous tibial nerve stimulation for the treatment of overactive bladder. J. Urol. 183, 234–240 (2010).

    Article  PubMed  Google Scholar 

  83. Peters, K. M., Carrico, D. J., Wooldridge, L. S., Miller, C. J. & Macdiarmid, S. A. Percutaneous tibial nerve stimulation (PTNS) for the long-term treatment of overactive bladder: three-year results of the STEP study. J. Urol. 189, 2194–2201 (2012).

    Article  PubMed  Google Scholar 

  84. Burton, C., Sajja, A. & Latthe, P. M. Effectiveness of percutaneous posterior tibial nerve stimulation for overactive bladder: a systematic review and meta-analysis. Neurourol. Urodyn. 31, 1206–1216 (2012).

    Article  CAS  PubMed  Google Scholar 

  85. Staskin, D. R., Peters, K. M., MacDiarmid, S., Shore, N. & de Groat, W. C. Percutaneous tibial nerve stimulation: a clinically and cost effective addition to the overactive bladder algorithm of care. Curr. Urol. Rep. 13, 327–334 (2012).

    Article  PubMed  PubMed Central  Google Scholar 

Download references

Author information

Authors and Affiliations

Authors

Contributions

J. Bartley researched data for the article. J. Bartley and J. Gilleran wrote the article. All authors contributed to the discussion of content and reviewed the manuscript before submission.

Corresponding author

Correspondence to Jamie Bartley.

Ethics declarations

Competing interests

K. Peters declares he has been a consultant for Medtronic and Uroplasty. J. Bartley declares she has been a speaker for Uroplasty. J. Gilleran declares no competing interests.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Bartley, J., Gilleran, J. & Peters, K. Neuromodulation for overactive bladder. Nat Rev Urol 10, 513–521 (2013). https://doi.org/10.1038/nrurol.2013.143

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1038/nrurol.2013.143

This article is cited by

Search

Quick links

Nature Briefing

Sign up for the Nature Briefing newsletter — what matters in science, free to your inbox daily.

Get the most important science stories of the day, free in your inbox. Sign up for Nature Briefing