Abstract
Neuromodulation elicited by electrical stimulation of peripheral or spinal nerves is a U.S. Food and Drug Administered (FDA)-approved therapy for treating disorders of the pelvic viscera, including urinary urgency, urgency-frequency, nonobstructive urinary retention and fecal incontinence. The technique is also being tested experimentally for its efficacy in treating interstitial cystitis, chronic constipation and pelvic pain. The goal of neuromodulation is to suppress abnormal visceral sensations and involuntary reflexes and restore voluntary control. Although detailed mechanisms underlying the effects of neuromodulation are still to be elucidated, it is generally believed that effects are due to stimulation of action potentials in somatic afferent nerves. Afferent nerves project to the lumbosacral spinal cord, where they release excitatory neurotransmitters that activate ascending pathways to the brain or spinal circuits that modulate visceral sensory and involuntary motor mechanisms. Studies in animals revealed that different types of neuromodulation (for example, stimulation of a sacral spinal root, pudendal nerve or posterior tibial nerve) act by releasing different inhibitory and excitatory neurotransmitters in the central nervous system. In addition, certain types of neuromodulation inhibit visceral smooth muscle by initiating reflex firing in peripheral autonomic nerves or excite striated sphincter muscles by initiating reflex firing in somatic efferent nerves. This report will provide a brief summary of (a) neural control of the lower urinary tract and distal bowel, (b) clinical use of neuromodulation in the treatment of bladder and bowel dysfunctions,
Highlights
The pelvic visceral organs perform essential excretory and sexual functions that are mediated by complex neural circuitry in the brain and spinal cord
The organs exhibit unique properties not shared by other visceral organs, including (a) complete dependence on central neural control, (b) excretory and sexual functions that are initiated in an all-or-none or switch-like manner, (c) functions that depend on coordination between multiple smooth and striated muscles and (d) voluntary control of micturition and defecation in contrast to the involuntary control of other visceral organs
Disorders of the lower urinary tract and distal bowel, such as overactive bladder syndrome (OAB), nonobstructive urinary retention, constipation and fecal incontinence, are commonly treated with behavioral therapy or drugs [4]; when patients are refractory to these first-line treatments or when treatment has to be terminated because of side effects, neuromodulation elicited by electrical stimulation of spinal nerve roots or peripheral nerves is often used [5,6]
Summary
The pelvic visceral organs perform essential excretory and sexual functions that are mediated by complex neural circuitry in the brain and spinal cord. Sacral neuromodulation is a U.S Food and Drug Administered (FDA)-approved therapy that involves permanent implantation of electrodes on spinal nerves at the sacral level along with implantation of a stimulator and battery at a more distant site [7]. Stimulation is usually applied continuously to obtain the optimal beneficial effects. Another type of FDA-approved office-based minimally invasive therapy involves stimulation of the posterior tibial nerve with electrodes inserted percuta-. NEUR OMODULATION OF PELVIC VISCERAL FUNCTIONS particular focus on bladder and bowel, how neural control is altered in pathological conditions and the putative mechanisms that underlie the normalization of bladder and bowel functions by neuromodulation
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