Patients who deal with sudden, urgent trips to the bathroom or leak urine before reaching the toilet may hear their providers mention tibial neuromodulation. The treatment sends a gentle electrical pulse through a nerve near the ankle, which travels up to the nerves that control the bladder and helps calm the urine urgency signals. 

To help patients better understand this treatment for overactive bladder, also known as urge urinary incontinence, urologist Kerri Thurmon, MD, answered some of the most common questions patients ask about the procedure, who it’s for and what recovery looks like. 

Q&A

What is tibial neuromodulation and how does it work?

"There is a large nerve called the tibial nerve that runs on the back of the leg and in the ankle that actually inserts into the spinal cord, and that input can then affect urinary bladder function," Dr. Thurmon said. "So when we stimulate that nerve at the ankle level, we can improve urge urinary incontinence, so urgency, frequency and leaks. This is a subconscious process. We're just restoring that brain-bladder connection, so the bladder becomes more effective because it's being modulated at the neural level."

Who is a good candidate for tibial neuromodulation?

According to Dr. Thurmon, the treatment currently has FDA approval for a specific group of patients. "Currently the FDA has only approved this for urge urinary incontinence," she said. "So what that means is patients have to have wet incontinence. They have to leak. Any patient that wears a pad because of leakage, or goes to the bathroom urgently and frequently, is a candidate."

She added that because the implant is placed in the ankle, where blood supply is less robust than near the heart, patients with significant lower leg swelling, venous disease or neuropathy in the legs and feet may not be ideal candidates. "It makes sense that nerve may not be as effective downstream," she said of patients with reduced sensation. For most other patients, though, she said the procedure is straightforward and low risk.

What does the tibial neuromodulation procedure involve?

Dr. Thurmon described it as a same-day procedure that doesn't require anesthesia. "I use local numbing medication in the ankle. I use a tool to mark out the location of the implant, make one small incision, and use the tool to then create a path for a battery that we implant right under the skin," she said. Patients receive dissolving stitches and a dressing, and can drive themselves home the same day.

Recovery is brief but does come with some restrictions. "You just have to wear a compression stocking for 72 hours, and then you have to really be easy on the ankle for about four weeks," Dr. Thurmon said. "No skiing, hiking, running or jumping. Just take it easy."

The battery itself is small. "It's about the size of a nickel, a little thicker," she said. "It's minimally palpable under the ankle once it's there, but most patients can't even tell that it's there."

How fast does tibial nerve modulation work?

Once the device is implanted, stimulation begins right away, though noticeable improvement takes time. "You're at home three days a week for 30 minutes. It stimulates the tibial nerve, and we look for improvement in your urinary parameters," Dr. Thurmon said. "Typically, four to eight weeks after the implant, things will start improving. It's not immediate, but we do immediately turn it on."

The device is MRI-compatible, removable and has a battery life of about 15 years.

How is urge urinary incontinence different than incontinence from childbirth or other pelvic floor disorders?

Dr. Thurmon explained that overactive bladder and stress incontinence are two distinct conditions that are sometimes confused. "There are several different types of incontinence," she said. "Stress incontinence is more of a urethral issue, like when someone has had children and now leaks urine jumping on a trampoline. Overactive bladder is different. That's, 'I've got to go, I've got to go, and I can't make it, and I leak before I get to the bathroom.'"

She noted that many women experience both conditions at once, known as mixed incontinence. "When I'm with patients, I always ask which one bothers you most, and then we start with treatment of that area," she said. "Typically things can get better if we just focus on the thing that bothers you the most."

What have you seen in your own patients since starting to offer this treatment?

Dr. Thurmon began offering the implant earlier this year after training at a cadaver lab sponsored by Medtronic. She said she's been struck by how smoothly the procedure goes for patients and how quickly many of them notice a difference. "Within a couple of stimulations, patients were having huge improvements in their incontinence, even within a couple of days," she said. "I don't ever want to promise that, because we will continue to see improvement out to four to eight weeks, but it's a pretty amazing thing that it works so quickly."

What would you say to patients who think urinary incontinence is just something they have to live with?

Dr. Thurmon said she often hears from patients, especially those who are older or who have had children, that they've come to accept incontinence as a normal part of life. She pushed back on that idea. "I think sometimes this diagnosis is perceived as lower on our hierarchy of needs," she said. "But it's a huge quality of life issue. Going to the bathroom is something we all do. This problem is worth treating. Just come see me, and I'm happy to talk you through the options."

To learn more about Kerri Thurmon, MD, who practices at CU Medicine Urology – South Denver at Highlands Ranch Pavilion 1, call 303-265-3940.