Lower urinary tract symptoms (LUTS) significantly impact quality of life, requiring multimodal management strategies. Concerning storage symptoms, one of the main purposes of treatment is to increase bladder capacity and achieve a proper bladder training. While transcutaneous tibial nerve stimulation (TTNS) is an established treatment for overactive bladder (OAB), its role in broader clinical entities and in combination with other therapies remains under investigation. This study evaluates the outcomes of TTNS across a diverse LUTS population, including its use alongside pelvic floor muscle training (PFMT) and pharmacotherapy.

A real-life, prospective, non-interventional cohort study was conducted on patients who underwent TTNS between 2019-2024 in a specialized clinical center. The standardized protocol consisted of 30-minute daily stimulation sessions for 3–6 months (20Hz frequency, 200μs pulse width, continuous mode), with pulse amplitude defined by patient’s motor and sensitive response. Bladder diary variables and the Patient Global Impression of Change (PGI-C) were assessed pre- and post-treatment. Medication discontinuation and need for further treatment were also recorded. Statistical analysis included the Wilcoxon signed-rank and Kruskal-Wallis tests using SPSS version 30.

Among 188 patients who underwent TTNS, 117 had adequate follow-up (mean age 47.3 ± 2.2 years, minimum and maximum 6-90; 59% female). Indications for treatment included OAB (65.8%), chronic pelvic pain (13.7%), neurogenic bladder (13.7%), low bladder capacity (4.3%), and nocturnal enuresis (2.6%). Urodynamic studies were available in 59% of patients, which revealed detrusor overactivity in 58%, bladder oversensitivity or urgency in 17.4%, decreased compliance in 20.3%, and detrusor underactivity in 43.5% of the patients.
TTNS was a first-line therapy in 37.6%, while others had prior treatments such as anticholinergics, mirabegron, percutaneous tibial nerve stimulation, botulinum toxin injections, or failed sacral neuromodulation. Treatment modalities included TTNS monotherapy (28.2%), TTNS+PFMT (32.5%), and various pharmacological combinations (detailed in Graph 1).
Significant improvements were observed in mean (± standard error of mean) daily micturitions (7.86±0.27 → 7.43±0.34, p=0.021), nocturia episodes (1.07±0.14 → 0.79±0.13, p=0.048), voided volume in mL (182.68±8.75 → 193.63±11.24, p=0.002), and bladder urgency episodes (2.58±0.38 → 1.29±0.29, p=0.003). While episodes of urgency urinary incontinence (0.39±0.09 → 0.22±0.08, p=0.059) showed a reduction, it was not statistically significant. The mean PGI-C score was 2.83±0.09, with no significant differences between treatment groups (p=0.313). Side effects were reported in two patients, namely stomachache and body shock waves, leading to discontinuation.
Following TTNS, 32.6% discontinued some type of medication, and 29.9% required no further treatment. The mean treatment duration was 4.46±0.30 months, while 40.2% continued TTNS as long-term therapy.

Our findings suggest that TTNS is a viable therapeutic option for a diverse range of LUTS, demonstrating efficacy both as a standalone treatment and as part of a multimodal approach. The patient cohort exhibited a broad age range, highlighting TTNS's applicability across different age groups. 
TTNS significantly improved daily micturitions, nocturia, voided volume, and bladder sensation, with 17.9% of patients discontinuing medication reinforcing its role as a potential alternative for patients seeking to reduce the need for oral medication. The median PGI-C score of 3 highlights patients’ improvement perception after TTNS. Notably, no significant differences in PGI-C scores were observed between treatment groups, suggesting that TTNS provides comparable symptom relief regardless of whether it is used in isolation or combined with other therapies.
The considerable proportion of patients who discontinued treatment without additional therapy suggests TTNS’s standalone efficacy in a medium-term, while those continuing treatment support its role in multimodal strategies.

TTNS is a valuable, non-invasive option for LUTS management, demonstrating benefits both as monotherapy and in combination approaches, supporting its flexibility within a multimodal treatment paradigm, allowing for individualized patient management. Study limitations include its clinical heterogeneity, warranting further prospective research.