Current Urology Reports

, 20:55 | Cite as

What Is New in Neuromodulation?

  • Courtenay K. MooreEmail author
  • Jessica J. Rueb
  • Samir Derisavifard
Lower Urinary Tract Symptoms & Voiding Dysfunction (J Sandhu, Section Editor)
Part of the following topical collections:
  1. Topical Collection on Lower Urinary Tract Symptoms & Voiding Dysfunction


Neuromodulation encompassing sacral and peripheral modalities is an established, effective, and safe higher-order treatment option approved in the USA for managing refractory overactive bladder, non-obstructive urinary retention, and fecal incontinence. This review highlights the most recent literature, indications, treatment durability, and the latest innovations in this field. Regarding sacral neuromodulation (SNM), recent work suggests improved parameters for optimal lead placement, increased data to support the lasting effects of treatment, and novel applications of this technology to other pelvic disorders. In addition, there are emerging technologies with smaller MRI compatible devices. Newer data on percutaneous tibial nerve stimulation (PTNS) suggests it may be more beneficial for certain patients. With new technology, implantable tibial nerve stimulators are ushering in a new frontier of nerve stimulation in the comfort of the patient’s home.


Neuromodulation Sacral neuromodulation LUTS PTNS Tibial nerve stimulators 


Compliance with Ethical Standards

Conflict of Interest

Courtenay K. Moore, Jessica J. Rueb, and Samir Derisavifard each declare no potential conflicts of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.


Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    Gormley EA, Lightner DJ, Faraday M, Vasavada SP. American Urological Association, Society of Urodynamics FPM. Diagnosis and treatment of overactive bladder (non-neurogenic) in adults: AUA/SUFU guideline amendment. J Urol. 2015;193(5):1572–80.CrossRefGoogle Scholar
  2. 2.
    Liberman D, Ehlert MJ, Siegel SW. Sacral neuromodulation in urological practice [Internet]. Vol. 99, Urology. Elsevier; 2017 [cited 2018 Sep 23]. p. 14–22. Available from:
  3. 3.
    Das AK, Abello A. Electrical neuromodulation in the management of lower urinary tract dysfunction: evidence, experience and future prospects Alejandro. Ther Adv Urol. 2018;10(5):165–73.CrossRefGoogle Scholar
  4. 4.
    Stewart F, Gameiro LF, El Dib R, Gameiro MO, Kapoor A, Amaro JL. Electrical stimulation with non-implanted electrodes for overactive bladder in adults. Cochrane Database Syst Rev. 2016.Google Scholar
  5. 5.
    Van de Borne S, Vaganée D, De Win G, Kessler TM, De Wachter S. Sacral neuromodulation using the standardized tined lead implantation technique with a curved vs a straight stylet: 2-year clinical outcomes and sensory responses to lead stimulation. BJU Int. 2018.Google Scholar
  6. 6.
    Gilleran J, Killinger K, Boura J, Peters K. Number of active electrodes at time of staged tined lead interstim implant does not impact clinical outcomes. Neurourol Urodyn. 2016;35:625–9.CrossRefGoogle Scholar
  7. 7.
    Pizarro-Berdichevsky J, Gill BC, Clifton M, Okafor HT, Faris AE, Vasavada SP, et al. Motor response matters: optimizing lead placement improves sacral neuromodulation outcomes. J Urol. 2018;199(4):1032–6. Scholar
  8. 8.
    • Siegel S, Noblett K, Mangel J, Bennett J, Griebling TL, Sutherland SE, et al. Five-year followup results of a prospective, multicenter study of patients with overactive bladder treated with sacral neuromodulation. J Urol. 2018;199(1):229–36. Five-year results indicating longevity of response of sacral neuromodulation with InterStim for patients with urgency/frequency and urge incontinence. CrossRefPubMedGoogle Scholar
  9. 9.
    Gross C, Habli M, Lindsell C, South M. Sacral neuromodulation for nonobstructive urinary retention: a meta-analysis. Female Pelvic Med Reconstr Surg. 2010;16(4):249–53.CrossRefGoogle Scholar
  10. 10.
    Mehmood S, Altaweel WM. Original article long-term outcome of sacral neuromodulation in patients with idiopathic nonobstructive urinary retention: single-center experience. Urol Ann. 2017;9(3):244–8 Available from: Scholar
  11. 11.
    De Ridder D, Ost D, Bruyninckx F. The presence of Fowler’s syndrome predicts successful long-term outcome of sacral nerve stimulation in women with urinary retention. Eur Urol. 2007;51(1):229–34.CrossRefGoogle Scholar
  12. 12.
    Janssen PTJ, Kuiper SZ, Stassen LPS, Bouvy ND, Breukink SO, Melenhorst J. Fecal incontinence treated by sacral neuromodulation: long-term follow-up of 325 patients. Surgery (United States). 2017;161(4):1040–8. Scholar
  13. 13.
    Hanno PM, Erickson D, Moldwin R, Faraday MM. American urological association. Diagnosis and treatment of interstitial cystitis/bladder pain syndrome: AUA guideline amendment. J Urol. 2015;193(5):1545–53.CrossRefGoogle Scholar
  14. 14.
    Gajewski JB, Al-Zahrani AA. The long-term efficacy of sacral neuromodulation in the management of intractable cases of bladder pain syndrome: 14 years of experience in one centre. BJU Int. 2011;107(8):1258–64.CrossRefGoogle Scholar
  15. 15.
    Vancaillie T, Kite L, Howard E, Chow J. Sacral neuromodulation for pelvic pain and pelvic organ dysfunction: a case series. Aust N Z J Obstet Gynaecol. 2018;58(1):102–7.CrossRefGoogle Scholar
  16. 16.
    Thaha MA, Abukar AA, Thin NN, Ramsanahie A, Knowles CH. Sacral nerve stimulation for faecal incontinence and constipation in adults. Cochrane Database Syst Rev. 2015 Aug 24 [cited 2019 May 10];(8). Available from:
  17. 17.
    van der Wilt AA, van Wunnik BPW, Sturkenboom R, Han-Geurts IJ, Melenhorst J, Benninga MA, et al. Sacral neuromodulation in children and adolescents with chronic constipation refractory to conservative treatment. Int J Color Dis. 2016;31(8):1459–66. Scholar
  18. 18.
    Iacona R, Ramage L, Malakounides G. Current state of neuromodulation for constipation and fecal incontinence in children: a systematic review. Eur J Pediatr Surg. 2019.Google Scholar
  19. 19.
    Hameury F, Ravasse P, Hery G, Baumstarck-Barrau K, Aubert D, Guys JM, et al. Sacral neuromodulation in children with urinary and fecal incontinence: a multicenter, open label, randomized, crossover study. J Urol. 2010;184(2):696–701. Scholar
  20. 20.
    Sharifiaghdas F. Sacral neuromodulation in congenital lumbo-sacral and traumatic spinal cord defects with neurogenic lower urinary tract symptoms: a single-center experience in children and adolescents. World J Urol. 2019 Mar 12 [cited 2019 May 10];1–9. Available from:
  21. 21.
    Lloyd JC, Gill BC, Pizarro-Berdichevsky J, Goldman HB. Removal of sacral nerve stimulation devices for magnetic resonance imaging: what happens next? Neuromodulation. 2017;20(8):836–40.CrossRefGoogle Scholar
  22. 22.
    Quirouet A, Bhattacharyya PK, Dielubanza EJ, Gill BC, Jones SE, Goldman HB. Sacral neuromodulation device heating during lumbar and pelvic magnetic resonance imaging—a phantom study. Urology. 2017;107:61–6. Scholar
  23. 23.
    •• Guzman-Negron JM, Pizarro-Berdichevsky J, Gill BC, Goldman HB. Can lumbosacral magnetic resonance imaging be performed safely in patients with a sacral neuromodulation device? An in vivo prospective study. J Urol. 2018;200(5):1088–92. A pilot study describing 11 patients who underwent a lumbar MRI with an active InterStim, with no significant adverse effect or malfunction. CrossRefPubMedGoogle Scholar
  24. 24.
    •• Blok B, Perrouin-Verbe MA, Elneil S, Van Kerrebroeck P, Van der Aa F, de Wachter S, et al. A prospective, multicenter study of a novel, miniaturized rechargeable sacral neuromodulation system: 12-month results from the RELAX-OAB study. Neurourol Urodyn. 2018;1–7. One-year results of the newest technology for sacral neuromodulation, Axonics the rechargeable, MRI-conditional device. Google Scholar
  25. 25.
    Amend B, Toomey P, Badke A, Sievert K-D, Kaps HP, Gakis G, et al. Early sacral neuromodulation prevents urinary incontinence after complete spinal cord injury. Ann Neurol. 2009;67(1):74–84.Google Scholar
  26. 26.
    •• Redshaw JD, Lenherr SM, Elliott SP, Stoffel JT, Rosenbluth JP, Presson AP, et al. Protocol for a randomized clinical trial investigating early sacral nerve stimulation as an adjunct to standard neurogenic bladder management following acute spinal cord injury. BMC Urol. 2018;18(1):72 This protocol outlines the future plans to test SNM in the prevention of urologic conditions after spinal cord injury. Once patients are accrued, a positive response to this therapy could change the management of these patients. CrossRefGoogle Scholar
  27. 27.
    Peters KM, Carrico DJ, Perez-Marrero RA, Khan AU, Wooldridge LS, Davis GL, 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. 2010;183(4):1438–43.CrossRefGoogle Scholar
  28. 28.
    Schneider MP, Gross T, Bachmann LM, Blok BFM, Castro-Diaz D, Del Popolo G, et al. Tibial nerve stimulation for treating neurogenic lower urinary tract dysfunction: a systematic review. Eur Urol. 2015;68(5):859–67.CrossRefGoogle Scholar
  29. 29.
    Rostaminia G, Chang C, Pincus JB, Sand PK, Goldberg RP. Predictors of successful percutaneous tibial nerve stimulation (PTNS) in the treatment of overactive bladder syndrome. Int Urogynecol J. 2018.Google Scholar
  30. 30.
    Peters KM, Shen L, Mcguire M. Effect of sacral neuromodulation rate on overactive bladder symptoms: a randomized crossover feasibility study. LUTS. 2013;5:129–33.PubMedGoogle Scholar
  31. 31.
    Burton C, Sajja A, Latthe PM. Effectiveness of percutaneous posterior tibial nerve stimulation for overactive bladder: a systematic review and meta-analysis. Neurourol Urodyn. 2012;31(8):1206–16.CrossRefGoogle Scholar
  32. 32.
    Peters KM, Carrico DJ, Wooldridge LS, Miller CJ, MacDiarmid SA. Percutaneous tibial nerve stimulation for the long-term treatment of overactive bladder: 3-year results of the STEP study. J Urol. 2013;189(6):2194–201.CrossRefGoogle Scholar
  33. 33.
    •• Salatzki J, Liechti MD, Spanudakis E, Gonzales G, Baldwin J, Haslam C, et al. Factors influencing return for maintenance treatment with percutaneous tibial nerve stimulation for the management of the overactive bladder. BJU Int. 2019;123(5A):E20–8 Largest study assessing factors contributing to PTNS maintenance therapy. CrossRefGoogle Scholar
  34. 34.
    • Sirls ER, Killinger KA, Boura JA, Peters KM. Percutaneous tibial nerve stimulation in the office setting: real-world experience of over 100 patients. Urology. 2018;113:34–9 Most comprehensive statement on patient non-compliance with PTNS. CrossRefGoogle Scholar
  35. 35.
    Ramírez-García I, Blanco-Ratto L, Kauffmann S, Carralero-Martínez A, Sánchez E. Efficacy of transcutaneous stimulation of the posterior tibial nerve compared to percutaneous stimulation in idiopathic overactive bladder syndrome: randomized control trial. Neurourol Urodyn. 2019;38(1):261–8.CrossRefGoogle Scholar
  36. 36.
    Thomas GP, Dudding TC, Bradshaw E, Nicholls RJ, Vaizey CJ. A pilot study to compare daily with twice weekly transcutaneous posterior tibial nerve stimulation for faecal incontinence. Color Dis. 2013;15(12):1504–9.CrossRefGoogle Scholar
  37. 37.
    Booth J, Connelly L, Dickson S, Duncan F, Lawrence M. The effectiveness of transcutaneous tibial nerve stimulation (TTNS) for adults with overactive bladder syndrome: a systematic review. Neurourol Urodyn. 2018;37(2):528–41.CrossRefGoogle Scholar
  38. 38.
    Shafik A, Ahmed I, El-Sibai O, Mostafa RM. Percutaneous peripheral neuromodulation in the treatment of fecal incontinence. Eur Surg Res. 2003;35(2):103–7.CrossRefGoogle Scholar
  39. 39.
    Hidalgo-Pujol M, Andriola V, Jimenez-Gomez LM, Ostiz F, Espin E. Medium-term outcome of percutaneous tibial nerve stimulation in the treatment of fecal incontinence. Tech Coloproctol. 2018;22(11):875–9.CrossRefGoogle Scholar
  40. 40.
    Simillis C, Lal N, Qiu S, Kontovounisios C, Rasheed S, Tan E, et al. Sacral nerve stimulation versus percutaneous tibial nerve stimulation for faecal incontinence: a systematic review and meta-analysis. Int J Color Dis. 2018;33(5):645–8.CrossRefGoogle Scholar
  41. 41.
    Venara A, Bougard M, Mucci S, Lemoult A, Le Naoures P, Darsonval A, et al. Perioperative transcutaneous tibial nerve stimulation to reduce postoperative ileus after colorectal resection: a pilot study. Dis Colon Rectum. 2018;61(9):1080–8.CrossRefGoogle Scholar
  42. 42.
    Brégeon J, Neunlist M, Bossard C, Biraud M, Coron E, Bourreille A, et al. Improvement of refractory ulcerative proctitis with sacral nerve stimulation. J Clin Gastroenterol. 2015;49(10):853–7.CrossRefGoogle Scholar
  43. 43.
    Musco S, Serati M, Lombardi G, Lumi E, Parisi AI, Del Popolo G, et al. Percutaneous tibial nerve stimulation improves female sexual function in women with overactive bladder syndrome. J Sex Med. 2016;13(2):238–42.CrossRefGoogle Scholar
  44. 44.
    Zimmerman LL, Rice IC, Berger MB, Bruns TM. Tibial nerve stimulation to drive genital sexual arousal in an anesthetized female rat. J Sex Med. 2018;15(3):296–303.CrossRefGoogle Scholar
  45. 45.
    Zimmerman LL, Gupta P, O’Gara F, Langhals NB, Berger MB, Bruns TM. Transcutaneous electrical nerve stimulation to improve female sexual dysfunction symptoms: a pilot study. Neuromodulation Technol Neural Interface. 2018;21(7):707–13.CrossRefGoogle Scholar
  46. 46.
    Katz M, DeRogatis LR, Ackerman R, Hedges P, Lesko L, Garcia M, et al. Efficacy of flibanserin in women with hypoactive sexual desire disorder: results from the BEGONIA trial. J Sex Med. 2013;10(7):1807–15.CrossRefGoogle Scholar
  47. 47.
    van Breda HMK, Martens FMJ, Tromp J, Heesakkers JPFA. A new implanted posterior tibial nerve stimulator for the treatment of overactive bladder syndrome: 3-month results of a novel therapy at a single center. J Urol. 2017;198(1):205–10. Scholar
  48. 48.
    •• Heesakkers JPFA, Digesu GA, van Breda J, Van Kerrebroeck P, Elneil S. A novel leadless, miniature implantable tibial nerve neuromodulation system for the management of overactive bladder complaints. Neurourol Urodyn. 2018;37(3):1060–7 Six-month results showing efficacy and safety of RENOVA iStim™ implantable tibial neurostimulator. CrossRefGoogle Scholar
  49. 49.
    •• MacDiarmid S, Kaaki B, Staskin DR, Clark M, Meffan P, Sand PK, et al. Feasibility of a fully implanted, nickel sized and shaped tibial nerve stimulator for the treatment of overactive bladder syndrome with urgency urinary incontinence. J Urol. 2018. Three-month results showing efficacy and safety of eCoin™ implantable tibial neurostimulator.CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  • Courtenay K. Moore
    • 1
    Email author
  • Jessica J. Rueb
    • 1
  • Samir Derisavifard
    • 1
  1. 1.Glickman Urologic and Kidney InstituteCleveland ClinicClevelandUSA

Personalised recommendations