A CLINICAL PERSPECTIVE ON TARGET SELECTION IN THE TREATMENT OF PELVIC DISORDERS

Introduction

Neuromodulation has become an established therapeutic option for patients suffering from overactive bladder (OAB) and other pelvic floor disorders. Over the past decades, approaches such as sacral neuromodulation and posterior tibial nerve stimulation have demonstrated clinically relevant efficacy and have been incorporated into international guidelines.

Recent innovations, including implantable tibial nerve stimulation systems such as the Altaviva system, aim to simplify therapy delivery and improve patient accessibility by reducing procedural complexity.

While these developments represent important progress, they also raise a fundamental scientific question:

Which neural targets should be stimulated to achieve optimal modulation of pelvic organ function?

Indirect Neuromodulation: Established but Limited

Most currently available neuromodulation techniques rely on indirect pathways. Posterior tibial nerve stimulation, whether percutaneous or implantable, modulates bladder activity via reflex circuits involving the sacral spinal cord.

Although effective in a subset of patients, this approach does not directly target the pelvic autonomic and somatic nerves responsible for bladder, sexual, and pelvic floor function.

This may partly explain:

  • variability in response rates 
  • incomplete symptom control in some patients 
  • the need for repeated or long-term stimulation protocols 

Direct Pelvic Neuromodulation: A Physiological Rationale

Pelvic organ function is controlled by a complex network of autonomic and somatic nerves, including the sacral plexus and genital nerves.

Over more than 20 years, clinical experience with genital nerve stimulation has demonstrated that direct modulation of these pathways can influence:

  • bladder function 
  • pelvic pain 
  • sexual function 

Initially performed using external surface electrodes, genital nerve stimulation provided important proof-of-concept for the role of targeted pelvic neuromodulation.

From External Stimulation to Chronic Implantation

A major limitation of early approaches was the lack of reproducibility and long-term applicability.

Recent advances have enabled the transition toward chronic implantable neuromodulation, using:

  • minimally invasive techniques 
  • percutaneous access 
  • short operative times 
  • procedures feasible under local anesthesia 

These developments allow a standardized and reproducible implantation, representing a key step toward broader clinical adoption.

Integration into Gynecological Practice

Despite the high prevalence of pelvic disorders such as OAB, neuromodulation has historically remained largely outside routine gynecological practice.

One of the main barriers has been:

  • procedural complexity 
  • lack of accessible techniques 
  • dependence on specialized centers 

The development of simple, reproducible, and minimally invasive implantation techniques targeting pelvic nervesopens the possibility for a paradigm shift.

For the first time, neuromodulation may become:

  • directly accessible to gynecologists 
  • integrated into daily clinical practice 
  • aligned with the anatomical expertise of the specialty 

Conclusion

The evolution of neuromodulation in pelvic medicine is entering a new phase.

While simplification of existing techniques — as illustrated by implantable tibial nerve systems — represents an important step forward, the next critical development lies in target selection.

Direct pelvic neuromodulation offers a physiologically grounded approach that may complement and potentially extend current therapeutic strategies.

Future research will determine its role within the therapeutic landscape, but its integration into gynecological practice may represent a key step toward a more comprehensive and anatomically targeted management of pelvic disorders.

References

  1. American Urological Association / Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction
    Guideline on the Diagnosis and Treatment of Overactive Bladder (Non-Neurogenic OAB), 2019 (amended 2024) 
  2. MacDiarmid SA et al.
    Long-term outcomes of tibial nerve stimulation for OAB
    Journal of Urology
  3. Medtronic.
    Clinical data on Altaviva system and TITAN-2 study results 
  4. Peters KM et al.
    Percutaneous tibial nerve stimulation: mechanisms and outcomes
    Neurourology and Urodynamics
  5. Possover M.
    Clinical experience in pelvic nerve stimulation and neuropelveology (various publications)