Overactive bladder (OAB) is a condition that has physical, social, psychosocial, and financial impacts. [1] OAB symptoms commonly have a significant impact on an individual’s overall well-being, with lower quality of life (QoL) scores consistently reported in people diagnosed with OAB. Current first line of treatment for OAB involves behavioural and lifestyle modifications such as caffeine and fluid restrictions and education around bladder training and frequency. A combination of these educational strategies have been shown to improve symptom severity and QoL in large patient cohorts; however, most evidence is low quality and not specific to OAB [2]. Percutaneous tibial nerve stimulation (PTNS) is one treatment modality commonly used to treat OAB. It requires specialised equipment and a trained health professional to administer a needle close to the tibial nerve. Transcutaneous tibial nerve stimulation (TTNS) is a modality that stimulates the nerve root fibres of L5-S3, the same spinal segments of the parasympathetic nervous system as the bladder [3]. It is more accessible to patients as they can self-administer it at home. Limited quality evidence is available to help clinicians choose if TTNS is a viable option as a first-line treatment option for OAB.

A review of the literature was undertaken, and 15 articles met our inclusion criteria for analysis .  We explored the indications for use based on symptomatic/ patient profiles. TTNS, when compared with sham treatment, parasacral stimulation, pelvic floor muscle training (PFMT), anticholinergic medication, and PTNS can provide symptomatic relief from urinary incontinence, frequency, urgency, and nocturia, while avoiding the bothersome side effects of more invasive or pharmaceutical therapies. TTNS has efficacy equal to PFMT and PTNS in the management of OAB when compared to anticholinergic medication.

Due to the heterogeneity of studies, it is unclear what the optimum parameters are for the use of TTNS for the treatment of OAB. Duration was consistently 30 minutes and applied continuously for most studies, whilst frequency varied from daily to weekly (mean 2.93 days) with time frames ranging 4 to 12 weeks (mean 7.78 weeks). The frequency (Hz) of TTNS ranged from 1-20 Hz and pulse widths 200-300uS. Intensity was either set or increased to maximum tolerance. Eleven of fifteen studies stated similar electrode placements, being from medial malleolus to within 10 cm proximally and four did not specify apart from at ankle over the tibial nerve or medial region of ankle. Until more research is done, these parameters should be used as a starting point when applying TTNS.

TTNS is a promising first-line management option for people with OAB, particularly in the older population and for those with neurogenic bladder. The lack of side effects and adverse events and the ease of use, non-invasiveness and low cost are some of the reasons TTNS should be considered before other, more invasive, modalities such as PTNS.

Future research exploring the understanding of the pathophysiologic contributors from TTNS on bladder function may assist in addressing the methodologic heterogeneities currently making comparison between modalities difficult. Exploring symptomatic changes in differing patient groups comparing modalities will allow patients and clinicians to make better informed choices for treatment. Long term effectiveness and cost comparison also need to be explored.

Haylen, B.T., et al., An international urogynecological association (IUGA)/international continence society (ICS) joint report on the terminology for female pelvic floor dysfunction. Neurourology and Urodynamics, 2010. 29(1): p. 4-20.
Kammerer-Doak, D., et al., Mixed urinary incontinence: international urogynecological association research and development committee opinion. International Urogynecology Journal, 2014. 25(10): p. 1303-1312.
Padilha, J.F., et al., Different electrode positioning for transcutaneous electrical nerve stimulation in the treatment of urgency in women: a study protocol for a randomized controlled clinical trial. Trials, 2020. 21(1): p. 166