In a woman with urgency incontinence who responded to office percutaneous tibial nerve stimulation but cannot sustain the maintenance visits, do you pursue an implantable tibial stimulator or move to sacral neuromodulation?

The main question to be answered is (as always) what the patient's goals are. Since SNM is typically mentioned as an option at the same time as PTNS/ITNS, there is typically either a patient-centric (e.g., patient likes the idea of a truly minimally invasive option and doesn't mind multiple clinic visits) or physician-centric reason (e.g., patient is not healthy enough to have multiple procedures +/- anesthesia for SNM) for choosing PTNS over SNM first. Having this discussion again is worthwhile...

There is no high-level data to support the next step, but to transition to an implantable TNS makes sense due to her positive response to percutaneous TNS.

This is an interesting question, and my answer isn't based on any literature. In my practice, all patients are ideally counselled regarding all advanced therapies. When we first offered PTNS, I was sure that in our rural area, patients who had success with it would quickly move to SNS. I haven't really seen that happen. I don't think we fully understand why patients choose one therapy over another. The patient who chooses PTNS may have reasons that we don't understand, which means they won't con...