Why Gynecology Still Has Nothing in Hand for the Treatment of
Overactive Bladder and why the GNS procedure is needed in
Gynecology: The Neglected Frontier of Neuromodulation
Possover Marc, MD, PhD
Despite decades of progress in gynecologic surgery and women’s health, the treatment of overactive bladder (OAB) remains a major unmet need in gynecology. Millions of women suffer from urinary urgency, frequency, and incontinence – symptoms that deeply affect quality of life, social integration, mental health, and professional productivity. Yet,
gynecologists – often the first and most trusted contact for female patients – are still left without effective tools beyond behavioral training and medications, which are often poorly tolerated or ineffective. Why is this the case?
The Clinical Dilemma
Overactive bladder affects 10–20% of women globally, and its prevalence increases with age.
The standard treatment pathway is well-established: pelvic floor exercises, behavioral modifications, and anticholinergic or beta-3 agonist medications. rates for pharmacologic therapies are staggeringly high – up to 90% within a few months – due to limited efficacy and intolerable side effects such as dry mouth, constipation, and cognitive impairment. Most patients turn to second- line therapies like Botox injections.
However,while Botox temporarily controls symptoms, it carries risks of bladder retention and urinary tract infections, often necessitating self-catheterization—a particular hardship for elderly or physically impaired patients. Botox is also contraindicated in men with enlarged prostate,means 50% of men between the ages of 51 and 60; 70% among men aged 60 to 69; around 80% of men over 70 years of age.
In this context, neuromodulation – particularly sacral nerve stimulation (SNM) – has proven effective in urology. But despite its success, neuromodulation remains nearly absent from gynecologic practice. Only 0.35% of gynecologists offer SNM, and many are unaware or unequipped to adopt this treatment modality.
Why Neuromodulation Is Practically Inexistent in Gynecology
There are multiple interrelated reasons for this paradox:
1. Lack of Training and Integration: Neuromodulation techniques such as SNM originate from neuro-urology and require specific training in spinal and sacral surgical techniques. Gynecologists, traditionally trained in abdominal, vaginal, and laparoscopic surgery, are not familiar with these procedures and are often not certified to manage such devices or complications.
2. Infrastructure Barriers: SNM requires cystoscopy and urodynamic testing equipment, trial stimulations, multiple surgeries, intraoperative X-ray or ENG/EMG and regular programming consultations – none of which are standard in gynecologic practices. Post-implantation management often depends on neuro-urologists or industry technicians, which discourages gynecologists from initiating the therapy themselves.
3. Systemic Reimbursement and Workflow Limitations: Neuromodulation-related procedures and follow-up programming are rarely reimbursed under gynecologic billing systems. This makes it economically unattractive for gynecologists to offer these treatments. Additionally, the need for frequent in-person adjustments adds
workload with limited compensation.
4. Fear of Patient Loss: Referring patients to neuro-urologists for Botox or SNM may result in permanent transfer of care, as neuro-urologists maintain patient contact for follow-up and treatment. This creates a reluctance among gynecologists to initiate such referrals, thus maintaining a cycle of fragmented care.
5. Patient Fear and Inconvenience: SNM involves a surgical trial phase and a bulky implant near the buttock. Many patients are afraid of potential spinal complications, or the lifestyle limitations imposed by the devices recharging requirements and visibility
Limitations of External Stimulation Devices
External genital nerve stimulation systems such as peroneal/anterior tibial nerve stimulation systems, come with practical limitations:
- They do not allow continuous stimulation and may inadvertently reveal the patient diagnosis.The external energy source, typically worn at the knee or ankle, makes it apparent that the individual requires neuromodulation for bladder control.
- For example, wearing a cuff at the knee is impractical for women wearing dresses, and tight jeans may cause discomfort or hinder placement.
- Similarly, tibial neurostimulator at the ankle, although cleverly designed, can be
problematic for users wearing high heels or ski boots due to its placement near the outer ankle.
The Consequence: A Therapeutic Dead End
Because of these barriers, most gynecologists limit their OAB treatment to lifestyle advice and medications. Once these fail, patients often fall into a therapeutic void. They continue to suffer, switch providers, or seek repeated Botox injections despite complications like urinary retention and increased infection risks. In men, particularly those with prostate hypertrophy,these limitations are even more pronounced.
The Solution: Reimagining Neuromodulation for Gynecology
To overcome this gap, pelvic neuromodulation must be redesigned to align with gynecologic
practice. This means:
- Minimally invasive procedures without the need for trial stimulations or spinal access.
- Simple, outpatient techniques that gynecologists can perform without additional equipment.
- Compact, rechargeable devices that patients can manage at home, without constant clinical supervision.
- Training ecosystems such as the International School of Neuropelveology to upskill gynecologists in these advanced techniques.
Thus, sacral neuromodulation, pudendal nerve stimulation, and Botox are all effective and well-known therapies in neuro-urology, but their benefits are of little use in gynecology, since these therapies are absent in that field. Therefore, regardless of their advantages, they do not fill the enormous therapeutic gap in gynecology. Since GNS is an implantation technique familiar to gynecologists (TVT procedure), this method should fill the gap in women’s medicine.
The Genital Nerve Stimulation (GNS) System – A Paradigm Shift
The Genital Nerve Stimulation (GNS) procedure and the NeuroGyn Pelvic Neuromodulation System (PosStim), developed by Prof. Possover, exemplify this paradigm shift. Based on 30 years of clinical expertise, the GNS procedure uses a gynecologist-friendly technique, inspired by the retropubic TVT approach (but without risk for urethral and vascular injury),and offers an “all-in-one” therapy for urinary, sexual, and even systemic disorders like osteoporosis and depression.In contrast to traditional systems such as SNM or external tibial/peroneal nerve stimulators, GNS offers significant safety, usability, and discretion advantages
- Unlike SNM, GNS does not involve the spinal cord or sacral nerves, thereb eliminating the risk of spinal damage, infection, or nerve injury.
- GNS implantation is minimally invasive and entirely hidden, allowing patients to maintain normal lifestyles without stigma or visible devices.
- The GNS procedure for final device implantation is a percutaneous puncture technique
- inspired by the TVT procedure (retropubic passage of a mesh) without the risks of urethral damages and hematoma (the implantation is performed around 2 cm from the urethra and the plexus Santorini), the easiest and most performed procedure in Gynecology, simplifying training and adoption in Gynecology.
- The GNS ensures precise and personalized planning, optimizing treatment outcomes and setting new standards in patient care. The pre-implantation testing device designed by NeuroGyn removes the need for technicians during implantation and programming consultations, significantly reducing costs and complexity. This innovation supports the scalability of GNS, allowing thousands of patients to be treated simultaneously without procedural bottlenecks.
- The device allows for easy and discreet recharging, even in everyday life situations—using a small remote or patch discreetly placed in front of the pubic symphysis. Charging can continue unobtrusively even during surgery, at work, or in social situations, unlike SNM which often requires patients to lie down for hours to recharge the device located near the buttock.
Moreover, pre-implantation device testing and remote therapy adjustment features reduce the need for surgical revisions and repetitive programming sessions.
The limitations of external devices contrast sharply with the discreet, ergonomic, and life-compatible design of GNS.
Comparison of Practitioners' Tools for Overactive Bladder (OAB) Treatment
Integrating GNS Therapy into Gynecological Practice – A New Dimension in Women’s Health
The absence of neuromodulation in gynecology is not due to a lack of medical need or therapeutic efficacy- but due to systemic, educational, and logistical barriers. With new technologies tailored for gynecologic practice, such as GNS, the discipline can finally reclaim its role in the comprehensive management of pelvic dysfunctions. It is time to give
gynecologists a powerful tool in their hands – a tool that is not only medically effective but practically feasible and economically sustainable.
The integration of Genital Nerve Stimulation (GNS) into gynecological practice opens an entirely new field of application, significantly expanding its reach and impact in the care of women. A closer look at the current healthcare landscape highlights the pressing need for such an approach: In Berlin, there are 463 urologists, but only around 20 to 30 specialized
neuro-urologists who actually perform Sacral Neuromodulation (SNM). In contrast, there are 1,626 gynecologists who are not perfoming either Botox or SNM. This striking discrepancy clearly illustrates why GNS therapy has such high relevance in gynecological care.
Every gynecologist routinely sees patients suffering from Overactive Bladder (OAB) in their daily practice. If all of these patients were to be referred to the limited number of neuro-urologists, the system would be quickly overwhelmed and unable to meet the demand.
This is precisely where GNS therapy finds its meaningful place: it enables gynecologists to treat their patients directly within their own practice – by a physician they already know and trust. GNS does not compete with SNM or intravesical Botox therapy; rather, it complements them by filling a therapeutic gap in women’s medicine. GNS is a valuable extension of the treatment options available to gynecologists – offering an effective and practical solution for
patients who might otherwise remain untreated or face long referral delays. It allows for the timely and efficient management of OAB and other functional pelvic disorders within the field of gynecology, ultimately enhancing patient care and improving quality of life.
In emerging markets, where the high cost of neuromodulation therapies has been a
barrier, the affordability of GNS make it an attractive as well.
Only by adopting these innovations can we finally meet the needs of the millions of women
silently suffering from overactive bladder—and bring gynecology into the era of advanced neuromodulation.
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