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Welcome to this special deep dive.
If you're a nursing or advanced practice student gearing up for your clinicals, you are in the exact right place.
Yeah, totally.
Because today our mission is to really master chapter 59 from advanced health assessment of women.
Right.
And we are going strictly by the text breaking down percutaneous tibial nerve stimulation or PTNS.
Which is such a fascinating topic to teach.
I mean, it's this incredibly focused women's health assessment and procedure that just feels like a magic trick.
It really does.
I like to tell students to imagine, you know, trying to fix a faulty electrical grid in a house.
Oh, that's a good analogy.
Right.
Like normally you might think I have to rip up the floorboards, pull down the drywall, get right to the main breaker.
Which is invasive and messy.
Exactly.
But what if instead you could just plug a device into an outlet in the garage and it sends a signal backward through the wiring that resets the whole system.
And that is PTNS in a nutshell.
You are treating overactive bladder, OAB, by essentially stimulating the ankle.
It sounds wild, but we have to establish the why do we even need to know this?
Well, the clinical need is just massive.
We are talking about 34 million adults in the US with overactive bladder.
34 million.
That's huge.
Yeah.
And the incidence rates are so skewed.
Women suffer from urge incontinence at much higher rates than men.
It's like 9 .3 % of women compared to just 2 .6 % of men.
Oh yeah.
And that number just goes up as patients age, right?
Exactly.
But here is the most heartbreaking part, honestly.
Only about 40 % of these people actually seek treatment.
So the majority are just suffering in silence.
Right.
They stop traveling.
They map out every bathroom at the grocery store.
They avoid social stuff.
I mean, it's a huge psychological burden.
Which is exactly why you as a clinician need this in your toolkit.
So let's get into the what and the who.
What exactly is this?
So PTNS is an office -based, minimally invasive neuromodulation system.
It's basically a second line therapy.
And when you look at it, it really combines traditional acupuncture techniques with modern electrical pulse stimulation.
Yeah.
You're targeting the posterior tibial nerve.
And by stimulating that peripheral nerve, you're indirectly regulating the sacral nerve plexus.
Which controls the bladder maceration.
It's literally a backdoor entrance to the pelvic floor.
That's a great way to put it.
You're hijacking the peripheral wiring to fix a central problem.
But how do we know who gets this?
I mean, history taking has to be our first step, right?
Absolutely.
Because this is a second line treatment, your history taking guides the whole plan.
You are listening for patients who have either failed or just maxed out on more than two OAB medications.
Right.
Those anti -muscarinic meds.
The side effects on those are just, well, they're notorious.
Oh, they're awful.
Severe dry mouth, awful constipation.
A lot of patients just can't tolerate them.
Or they're just unwilling to take another daily oral pill.
Polypharmacy is a real issue.
Exactly.
And it's not just for standard adiopathic OAD either.
The patient profile's actually a lot wider.
Wait, really?
Who else is this indicated for?
Well, the text highlights that it's indicated for lower urinary tract symptoms, LUTs, in patients with multiple sclerosis, Parkinson's disease, spinal cord injuries.
Oh, wow.
Or even post -doc patients, right?
Right.
Anyone with those complex neurogenic bladders where the neural signaling is compromised.
So once your history shows they are a candidate, you have to immediately shift your clinical interpretation to safety.
Safety is everything here.
You have to rule out the heart stops before you even touch the patient's leg for an exam.
Let's run through those absolute contraindications.
Okay.
So pregnancy or even planning to get pregnant during the treatment.
Hard stop.
Makes sense.
Also, if they are prone to excessive bleeding because we are using needles, or if they have pre -existing nerve damage affecting the tibial nerve or pelvic floor.
Because if the wiring is broken, the electrical signal won't travel anyway.
Exactly.
And the big one pacemakers or implantable defibrillators.
Okay, wait, hold on.
If we are just stimulating the ankle, why is a pacemaker up in the chest a hard stop?
I get that question a lot from students.
It seems really far away, right?
Yeah.
It's like opposite ends of the body.
But you have to think about the electrophysiology.
We are introducing an external electrical current into the body's neural pathways.
Right.
Which are highly conductive.
Exactly.
So even though the current is supposed to just go to the sacral plexus, there is a theoretical but very serious risk of it interfering with any implanted electrical device.
Like crosstalk between the devices.
Yeah.
You just cannot risk messing with a pacemaker's sensing functions.
So absolutely no pacemakers.
Okay.
So history is done.
Safety is cleared.
The patient is definitely going to ask, does this actually work?
And you can confidently tell them yes.
The clinical buy -in is huge because 60 to 80 % of patients respond positively.
That's a massive success rate for second -line therapy.
It really is.
It significantly reduces their daytime and nighttime voiding, urge leaking, and even the volume leaked.
And the text points out that in head -to -head studies, it performs comparably to anticholinergics.
Yes.
But even better, it shows sustained long -term improvement in three -year studies.
Wow.
Three years.
But to get those results, you have to establish a really rigorous schedule right from the start.
The timeline is no joke.
It requires an initial phase of 12 weekly treatments.
So they are coming to the clinic once a week for three months.
Right.
And each session is about 30 to 60 minutes.
And what happens after those 12 weeks?
If it works, you taper them down, usually to about once a month for maintenance.
And if the symptoms start creeping back?
You just increase the frequency back to whatever interval kept them dry.
There are also alternative schedules, like intensive ones, where they come in up to three times a week for those first 12 sessions.
But the biggest thing here is managing expectations, right?
Oh, absolutely.
The text makes this super clear.
You have to tell them they might see improvement at two treatments, or it might take all 12.
I think most often the shift happens around the six -week mark, yeah?
Usually, yeah.
But the critical clinical pearl here, do not stop early.
Right.
Don't let them quit at week four just because they aren't totally fixed yet.
Exactly.
They must complete all 12 initial treatments before you can definitively say if it failed or not.
And you can't just rely on them saying, ah, I think I peed less this week.
You need objective measurements.
Bladder diaries are your best friend here.
You need a baseline diary, a week six diary, and a week 12 diary.
It's the only way to get actual data on their voiding changes.
Right.
Now, you also have to consent them for risks.
But luckily, they're really low.
Yeah, we're talking transient, mild or moderate pain, maybe some skin inflammation at the site.
Or just a tiny bit of mild bleeding from the needle.
Okay, so history taken, safety confirmed, protocol explained.
Now we move to the physical examination.
Yes, the focused leg exam.
You have to look at the lower extremities before you even pick up a needle.
What exactly are we looking to avoid?
You want to avoid ankles with any surgical hardware like plates or screws?
Because metal messes with the electrical field.
Exactly.
You also avoid legs or feet with no neuropathy.
If they can't feel it, you can't dose the current safely.
Right.
Plus, obviously, avoid any open areas, cellulitis or multiple spider veins.
You don't want to stick a vein.
No, you definitely do not.
And here is a fantastic clinical pearl from the text regarding patients with lower leg edema.
Oh, this is a great practical tip.
Tell them.
Schedule these patients in the morning when the swelling is at its lowest.
It makes finding the landmark so much easier before gravity pulls all that fluid down there.
It really does.
And just briefly on clinic management, you have to make sure you're using the correct ICD -10 codes.
Right, like N39 .41 for urgent continence.
Yep.
And the CPT code for the procedure is 64566.
You always want to check local Medicare or Medicaid plans to establish medical necessity.
Okay, the leg is clear, paperwork is done.
Let's walk through the actual step -by -step procedure.
First is the pre -procedure prep.
Baseline diary is done, informed consent is signed.
Covering efficacy, side effects, and making sure they're committed to the 12 weeks.
Right.
So you look at figure 59 .1 in the text.
The setup is simple.
Patient is seated comfortably, leg elevated, foot exposed and supported.
And your equipment.
You need a 34 gauge needle.
Which is tiny, by the way, like an acupuncture needle.
Very tiny.
You also need lead wires, a surface electrode pad, and an urgent PC stimulator device.
It's all right there in figure 59 .2.
So how do you find the exact landmark?
Okay, you go to the inner leg,
find the medial malleolus, that's the inner ankle bone.
Got it.
Measure approximately two inches above that bone, and then go one finger width posterior, so toward the back of the leg.
Okay, that's your spot.
Then you clean it with alcohol?
Yeah.
Then you insert that tiny needle at a 60 to 90 degree angle.
You only go about two centimeters deep.
And the goal here is proximity.
You want to get close to the tibial nerve, but you do not want to actually impale it.
Exactly.
Direct contact would hurt.
Once the needle is in, you apply the stimulation.
So you connect the lead to the handheld stimulator.
Right.
Attach the surface electrode pad to the arch or heel of the foot that grounds the circuit.
And then clip the little needle electrode onto the needle itself.
Yes.
Then you slowly turn up the current.
This is where your clinical interpretation comes in.
Because you're watching the patient's foot and asking what they feel.
You are looking for a motor response, like a slight toe flex or fanning, and a sensory response.
Which they usually describe as a vibration or tingling in the heel or foot.
Right.
But things don't always go perfectly on the first try, so you have to know the troubleshooting pathways.
Right.
So what if the patient says, ouch, that hurts?
Or they just feel a sharp pinch right at the needle site?
If it's uncomfortable, you immediately lower the current.
If it still hurts, reposition or just switch to the other leg.
And if they only feel it right at the needle insertion site?
That means you're too shallow.
Just push the needle a tiny bit further in.
And what if there's just zero response?
No toe flex, no tingling, nothing.
Then you adjust the needle angle or depth.
If you still get nothing, you just pull it and switch legs.
The key clinical fact here is that getting a combination of a sensory and a motor response yields the absolute best outcomes.
Yes, that combo is the sweet spot.
Once you hit that, you stimulate for 30 minutes.
And then you safely disconnect, pull the needle, and put it in a sharps container.
Procedure done.
But the clinical management isn't over.
You have to document meticulously to ensure continuity of care.
What exactly has to go on the chart?
You need the consent form, the HMP showing their bladder symptoms, the treatment log like, which leg, and what settings you used, and all their bladder records.
And the text includes a fantastic tool for this appendix 59 .1.
It's the PT &S worksheet.
It is so vital.
It tracks the onset of symptoms, all their previous conservative treatments.
Like how long they tried Kegels or biofeedback.
Right.
And it maps out the timeline of their failed meds, like Ditropan or Vesicare, and exactly why they stopped them.
Crucially, this worksheet documents the patient's actual goals.
Yes.
Whether that means they want to sleep through the night, or just stay dry during an entire work meeting without rushing out.
Tracking against those personal goals is how you know it's really working for their life.
It really shifts it to patient -centered care.
Now, looking forward, the text touches on some exciting future tech.
Because that 12 -week clinic burden is really heavy for a lot of people.
It is.
So, researchers are looking into implantable micro devices and surface electrodes for in -home use.
Which could completely revolutionize this therapy.
Imagine doing it on your couch while watching TV.
It would boost compliance so much.
Which actually leads me to a final thought I'd love to leave you with today.
Let's hear it.
When you look at the high failure rates and the miserable side effects of daily oral medications, I mean, up to 80 % of patients stop taking their OAB pills within a single year.
That's a staggering failure rate for a first -line treatment.
Right.
So, as you go into your clinical application, ask yourself,
could peripheral neuromodulation eventually move from being a second -line therapy to a first -line standard of care?
Are we going to eventually replace the pharmacy with electricity?
Wow.
That is a fantastic question to ponder.
A huge paradigm shift to think about as you start treating these patients.
Absolutely.
Keep looking for those backdoor entrances to healing.
Well said.
Thank you from the Last Minute Lecture Team.
You've got this.