Minimally Invasive Therapies for OAB: What the Guidelines Say

The 2024 AUA/SUFU guideline presents sacral neuromodulation (SNM), posterior tibial nerve stimulation (PTNS), and intradetrusor onabotulinumtoxinA (onabotA) as parallel options supported by Grade A evidence and a Moderate Recommendation for patients who have not had an adequate response to pharmacotherapy—a framing that positions clinical judgment and patient preference, rather than a ranked hierarchy, as the deciding factors. In the third segment of this series, Aleece Fosnight, MSPAS, PA-C, CSC-S, CSE, IF, MSCP, HAES founder, Fosnight Center for Sexual Health in Asheville, North Carolina, explains how she translates this evidence level into a confident, non-prescriptive recommendation. The Grade A designation, she notes, means the science confirms that all 3 therapies are effective and durable—it does not identify a best choice, because the right choice is determined by the individual patient's circumstances, not the evidence hierarchy alone.

Fosnight describes her decision-making conversations as structured brainstorming sessions that she conducts aloud with the patient, working through the practical realities of each option in turn. For PTNS, the conversation centers on schedule feasibility: 12 weekly in-office sessions followed by ongoing booster treatments, and whether that commitment is realistic for the patient's life. For onabotA, she reviews the procedural interval—injections every 5 to 6 months—alongside the possibility of temporary urinary retention requiring clean intermittent catheterization and the risk of urinary tract infection, prompting patients to weigh those risks against the appeal of a procedure-based rather than pill-based approach. For SNM, she addresses the implications of an implanted device: the surgical nature of the procedure, the potential for a 2-stage implantation process, and battery longevity considerations. She stresses that she wants patients to be fully candid about their concerns and fears before selecting an option, and that she deliberately tests their confidence in a given choice by walking through the full practical requirements before they commit.

Fosnight uses the analogy of a navigation application to characterize her role: She identifies the available routes and their trade-offs, but the patient remains in the driver's seat. This framing, she explains, is not simply a communication strategy—it reflects a clinical philosophy in which the best outcome is defined not by which therapy has the strongest efficacy signal in a randomized trial but by which therapy the individual patient will actually engage with, adhere to, and benefit from over time. She notes that none of the 3 options should be introduced as a last resort, and that presenting them from a position of confidence in the evidence—rather than as a concession that pills have failed—meaningfully changes how patients receive the information and how readily they move forward.