Editing AUA: Overactive Bladder (2019) (section)

=== Third-line ===

==== Options (3): ====

# '''<span style="color:#ff0000">Intradetrusor onabotulinumtoxinA'''
# '''<span style="color:#ff0000">Peripheral tibial nerve stimulation (PTNS)'''
# '''<span style="color:#ff0000">Sacral neuromodulation'''
* Before a patient is exposed to third-line therapies with increased risk compared to behavioral or medical therapy, the patient’s realistic desire for further treatment should be ascertained, and a comprehensive evaluation should be conducted to confirm the diagnosis of OAB and not another disease process

* Neuromodulation or onabotulinumtoxinA therapy may be offered to the carefully selected patient who has failed behavioral and anti-muscarinic therapy or who is not a candidate for these therapies and continues to have bothersome symptoms after appropriate counseling. 
*

==== OnabotulinumtoxinA ====
* '''<span style="color:#ff0000">Intradetrusor onabotulinumtoxinA (100U) may be offered as third-line treatment in the carefully-selected and thoroughly-counseled patient who has been refractory to first- and second-line OAB treatments.</span>'''
**'''<span style="color:#ff0000">Considered a treatment STANDARD in patients with moderate to severe OAB symptoms</span>'''
*'''<span style="color:#ff0000">Dosing: FDA-approved dose of 200U for neurogenic OAB</span>[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3649594/ §][https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4739988/ §]'''
**'''<span style="color:#ff0000">Not FDA-approved in non-neurogenic OAB patients, 100U typically used</span>'''
*'''<span style="color:#ff0000">Adverse events</span>'''
*#'''<span style="color:#ff0000">Urinary retention</span>'''
*#*<span style="color:#ff0000">'''The patient must be able and willing to return for frequent post-void residual evaluation and able and willing to perform self-catheterization if necessary.'''
*#'''<span style="color:#ff0000">Gross hematuria</span>''' 
*#'''<span style="color:#ff0000">UTI</span>'''
*#'''<span style="color:#ff0000">Dry mouth</span>'''
*#'''<span style="color:#ff0000">Dysphagia</span>'''
*#'''<span style="color:#ff0000">Impaired vision</span>'''
*#'''<span style="color:#ff0000">Eyelid weakness</span>'''
*#'''<span style="color:#ff0000">Arm weakness</span>'''
*#'''<span style="color:#ff0000">Leg weakness</span>'''
*#'''<span style="color:#ff0000">Torso weakness</span>'''
*'''Technique'''
**'''A randomized trial comparing trigone-including  versus trigone-sparing injections of abobotulinumtoxinA found greater symptom improvement in the trigone-including injected group'''
*'''<span style="color:#ff0000">Effects diminish over time for most patients; therefore, patients also should be informed that repeat injections are likely to be necessary to maintain symptom reduction</span>'''

==== Peripheral tibial nerve stimulation (PTNS) ====

* See [https://test.urologyschool.com/index.php/Functional:_Neuromodulation#Posterior_Tibial_Nerve_Stimulation_(PTNS) Posterior Tibial Selective Nerve Stimulation Chapter Notes]
*'''<span style="color:#ff0000">Indications</span>'''
**'''<span style="color:#ff0000">May offer peripheral tibial nerve stimulation (PTNS) as third-line treatment in a carefully selected patient population, characterized by moderately severe baseline incontinence and frequency and willingness to comply with the PTNS protocol.</span>'''
***Patients must also have the resources to make frequent office visits both during the initial treatment phase and to obtain maintenance treatments in order to achieve and maintain treatment effects.
**'''FDA-approved for OAB treatment'''
*<span style="color:#ff0000">'''Efficacy'''</span>
**<span style="color:#ff0000">'''Improves OAB symptoms with magnitude to anti-muscarinics, but PTNS has a better adverse event profile.'''</span>
*<span style="color:#ff0000">'''Adverse events (2):'''</span>
*#<span style="color:#ff0000">'''Painful sensation during stimulation'''</span>''' that did not interfere with treatment
*#<span style="color:#ff0000">'''Minor bleeding at the insertion site'''</span>

==== Sacral Neuromodulation ====

* <span style="color:#ff0000">'''May offer sacral neuromodulation (SNS) as third-line treatment in a carefully selected patient population characterized by severe refractory OAB symptoms or patients who are not candidates for second-line therapy and are willing to undergo a surgical procedure.'''</span>
*'''<span style="color:#ff0000">Adverse events</span>'''
*#'''<span style="color:#ff0000">Pain at the stimulator site</span>'''
*#'''<span style="color:#ff0000">Pain at the lead site</span>'''
*#'''<span style="color:#ff0000">Lead migration</span>'''
*#'''<span style="color:#ff0000">Infection/irritation</span>'''
*#'''<span style="color:#ff0000">Electric shock</span>'''
*#'''<span style="color:#ff0000">Need for surgical revision</span>'''
*#*In most studies, the need for surgical revision occurred in greater than 30% of patients.
*#'''<span style="color:#ff0000">Difficulty passing through airport metal detectors</span>'''
*#'''<span style="color:#ff0000">Inability to undergo magnetic resonance imaging (MRI)</span>'''
*#<span style="color:#ff0000">'''Adverse events more frequent than PTNS'''</span>
*#*There is some evidence that newer, less invasive surgical procedures and tined devices may be associated with fewer adverse events
*Patients should be counseled that the device requires periodic replacement in a planned surgical procedure and that the length of time between replacements depends on device settings. Patients also must be willing to comply with the treatment protocol because treatment effects typically are only maintained as long as the therapy is maintained and have the cognitive capacity to use the remote control to optimize device function. 
*