Sacral Neuromodulation Success in Overactive Bladder Unchanged by Pelvic Floor Physical Therapy

Objectives: Treatment options for overactive bladder (OAB) are varied. Conservative therapy with pelvic floor physical therapy (PFPT) or behavioral modification is typically first line. Oral therapies are second line, and third line treatments for refractory OAB include sacral neuromodulation (SNM). While PFPT is recommended as first line therapy, one study associated prior PFPT with higher failure rates in patients undergoing SNM placement for all indications. We examined the impact that PFPT completed prior to SNM had on treatment outcomes in women with OAB, and we predicted that prior PFPT would result in higher SNM success.

Methods: We performed a retrospective chart review from 2007 to 2021 of women who underwent SNM placement for OAB and had postoperative follow-up. Patients with pelvic pain, non-obstructive urinary retention, and fecal incontinence were excluded. We compared patients without prior preoperative PFPT (defined as 0 sessions), those that completed less than 13 PFPT sessions, and those that completed 13 or more sessions. The primary outcome was the proportion of patients with continued subjective improvement of >50% at 1, 3, 6, and 12 months after SNM implantation in patients who underwent prior PFPT compared to those who did not. ANOVA, Kruskal-Wallis test, Chi-square test, and Exact tests were used in analysis.

Results: Among the 208 women who underwent SNM implantation, mean age was 66.9 years (SD 16.2) and mean BMI was 31.2 kg/m² (SD 6.88). In this group, 158 (76.0%) underwent SNM without prior PFPT, 30 (14%) patients completed < 13 sessions, and 20 (10%) completed 13 or more sessions. Mean age and BMI differed amongst the groups. Success rates 1 month after SNM implantation were higher in patients without prior PFPT (131/147 or 89.1%) and in those that completed greater than 13 PT sessions (18/20 or 90%) compared to those who completed less than 13 sessions (19/29 or 65.6%), p< 0.01. There were no differences between the groups at 3-, 6-, and 12-months post implant, although 50% were lost to follow up after the initial 1-month visit.

Conclusions: Although PFPT prior to SNM did not result in durable improvement in SNM success in women with OAB, completing greater than 12 sessions (in those recommended PFPT) did result in better immediate success. Patients with refractory OAB may not benefit from additional PFPT prior to SNM, although more data is needed. Future studies should be prospective, and symptom evaluation should involve the use of standardized questionnaires at all time points studied.