Exploring Transcutaneous Tibial Nerve Stimulation: Part 1

Electrostimulation is a conservative treatment of improving bladder function. This can be performed parasacrally, intravaginally or by stimulation of the tibial nerve (Wang and Liu, 2022, Jacomo et al, 2020, Bhide et al 2019, Padilha et al., 2020).

Tibial Nerve Stimulation (TNS) is performed to assist patients to improve bowel and bladder function such as fecal incontinence, constipation, overactive bladder (OAB), painful bladder syndrome, pediatric voiding dysfunction, neurogenic bladder, urinary urgency (UU), and enuresis. Today we are going to explore tibial nerve stimulation for overactive bladder symptoms.

A 2025 systematic review and meta-analysis reviewed transcutaneous tibial nerve stimulation with OAB. All the studies reviewed revealed improvements in urinary symptoms through improved quality of life and OAB functional outcome scores or improvements with 3-day voiding diary measures such as urinary incontinence, urgency, frequency and nocturia (Vaca-Benavides et al., 2025).

How does TNS work for OAB?

Although research is still determining exact pathways, TNS is thought to work through retrograde neuromodulation of the sacral nerve plexus (L4-S3) via transmission of electrical signals from the ankle (distally) along the path of the posterior tibial nerve (more proximally) to the spinal cord, which is believed to suppress excessive or abnormal afferent signaling at the detrusor muscle, thereby inhibiting involuntary spasms and/or contractions (Shang et al., 2026, Vaca-Benavides et al., 2025, Sapouna, 2024).

TNS likely modulates neural pathways by stimulating peripheral somatic afferent nerves which to calm the bladder and inhibit the micturition reflex (Al-Danakh et al., 2022). Utilizing TNS long-term may reprocess the signals received by the bladder by inducing neural plastic changes over a longer period with repeated nerve stimulation (Kovacevic and Yoo, 2015). Repeated TNS sessions may also potentially assist with reorganization of the central nervous system’s sensory processing relieving detrusor overactivity (Sapouna, 2024).

Animal models also suggest a reduction of mast cells, which may reduce sensitivity and inflammation (Gaviev et al., 2013, Sapouna, 2024). In addition, stimulation in the animal models have reduced the expression of C-fos in the spinal cord, which is a marker of neuronal metabolic activity, which may lead to a downregulation in neuronal pathways (Sapouna, 2024).

What are different types of Tibial Nerve Stimulation (TNS)?

Shang et al, describe 3 main types of TNS utilized clinically.

The first type is Percutaneous Tibial Nerve Stimulation (PTNS), involves delivering low-voltage stimulation through the insertion of a needle-shaped electrode approximately 3-4cm above the medial malleolus.

The second type, Transcutaneous Tibial Nerve Stimulation (TTNS), is something we are more familiar with. This involves placing non-invasive use of electrode pads on the skin and utilizing a TENS unit to provide stimulation on the route of the posterior tibial nerve.

The third type is Implantable Tibial Nerve Stimulation (ITNS / iTNM), which involves surgically implanting electrodes near the tibial nerve for chronic stimulation with special units.

How can I learn to use TTNS?

To learn more about TTNS, as well as other forms of neuromodulation, take Modalities and Pelvic Function: The Pelvic Health Toolkit. In this course you learn how to integrate into your treatments numerous types of modalities including neuromodulation, biofeedback, estim, release tools, tools for sexual health, and modalities for urinary and fecal incontinence. Participants are introduced to many examples of modalities with hands on labs to practice the application of these tools. Join us June 27 and 28 in Milwaukee, Wisconsin for Modalities and Pelvic Function to learn more about frequently used modalities in pelvic health.

https://www.hermanwallace.com/continuing-education-courses/modalities-and-pelvic-function

References

Al-Danakh, A., Safi, M., Alradhi, M., Almoiliqy, M., Chen, Q., Al-Nusaif, M., Yang, X., Al-Dherasi, A., Zhu, X., & Yang, D. (2022). Posterior Tibial Nerve Stimulation for Overactive Bladder: Mechanism, Classification, and Management Outlines. Parkinson’s disease, 2022, 2700227. https://doi.org/10.1155/2022/270022

Barroso, U., Jr, & Lordêlo, P. (2011). Electrical nerve stimulation for overactive bladder in children. Nature reviews. Urology, 8(7), 402–407. https://doi.org/10.1038/nrurol.2011.68

Bhide, A. A., Tailor, V., Fernando, R., Khullar, V., & Digesu, G. A. (2020). Posterior tibial nerve stimulation for overactive bladder-techniques and efficacy. International urogynecology journal, 31(5), 865–870. https://doi.org/10.1007/s00192-019-04186-3

Cava, R., & Orlin, Y. (2022). Home-based transcutaneous tibial nerve stimulation for overactive bladder syndrome: a randomized, controlled study. International urology and nephrology, 54(8), 1825–1835. https://doi.org/10.1007/s11255-022-03235-z

Gaziev, G., Topazio, L., Iacovelli, V., Asimakopoulos, A., Di Santo, A., De Nunzio, C., & Finazzi-Agrò, E. (2013). Percutaneous Tibial Nerve Stimulation (PTNS) efficacy in the treatment of lower urinary tract dysfunctions: a systematic review. BMC urology, 13, 61. https://doi.org/10.1186/1471-2490-13-61

Jacomo, R. H., Alves, A. T., Lucio, A., Garcia, P. A., Lorena, D. C. R., & de Sousa, J. B. (2020). Transcutaneous tibial nerve stimulation versus parasacral stimulation in the treatment of overactive bladder in elderly people: a triple-blinded randomized controlled trial. Clinics (Sao Paulo, Brazil), 75, e1477. https://doi.org/10.6061/clinics/2020/e1477

Kovacevic, M., & Yoo, P. B. (2015). Reflex neuromodulation of bladder function elicited by posterior tibial nerve stimulation in anesthetized rats. American journal of physiology. Renal physiology, 308(4), F320–F329. https://doi.org/10.1152/ajprenal.00212.2014

Padilha, J. F., Avila, M. A., Seidel, E. J., & Driusso, P. (2020). Different electrode positioning for transcutaneous electrical nerve stimulation in the treatment of urgency in women: a study protocol for a randomized controlled clinical trial. Trials, 21(1), 166. https://doi.org/10.1186/s13063-020-4096-7

Sapouna, V., Zikopoulos, A., Thanopoulou, S., Zachariou, D., Giannakis, I., Kaltsas, A., Sopheap, B., Sofikitis, N., & Zachariou, A. (2024). Posterior Tibial Nerve Stimulation for the Treatment of Detrusor Overactivity in Multiple Sclerosis Patients: A Narrative Review. Journal of personalized medicine, 14(4), 355. https://doi.org/10.3390/jpm14040355

Shang, D., Deng, H., Li, C., Wang, Z., Jin, L., & Li, X. (2026). Tibial nerve stimulation for overactive bladder: a literature review of stimulation parameters. Translational andrology and urology, 15(2), 67. https://doi.org/10.21037/tau-2025-aw-774

Vaca-Benavides, D. A., Ju, W., Gonzalez, C., Aitken, P., Appukuttan Nair Syamala Amma, A. K., Mitra, S., & Shenkin, S. D. (2025). The importance of electrical parameters on transcutaneous tibial nerve stimulation for overactive bladder syndrome: a systematic review and meta-analysis. Age and ageing, 54(7), afaf203.

Wang, Z. H., & Liu, Z. H. (2022). Treatment for overactive bladder: A meta-analysis of tibial versus parasacral neuromodulation. Medicine, 101(41), e31165. https://doi.org/10.1097/MD.0000000000031165

Candido, T. A., Ribeiro, B. M., de Araújo, C. R. C., Pinto, R. M. C., Resende, A. P. M., & Pereira-Baldon, V. S. (2020). Effects of tibial and parasacral nerve electrostimulation techniques on women with poststroke overactive bladder: study protocol for a randomized controlled trial. Trials, 21(1), 936. https://doi.org/10.1186/s13063-020-04856-4