Initial Experience with Sacral Nerve Stimulation as a Treatment for Intractable Urge Incontinence

Abstract

Objective: To evaluate the efficacy of sacral nerve stimulation using a permanent implantable system in the treatment of intractable urge incontinence, urgency, frequency, and nocturia.Methods: Ten women with varying degrees of urinary urge incontinence, urgency, frequency, and nocturia were implanted with an Interstim® sacral nerve stimulation device. To be eligible for the implant, subjects must have failed biofeedback and pelvic electrical stimulation therapy and at least two anti-cholinergic drugs. These women had tried at least two of tolterodine, oxybutynin, and imipramine. They then underwent a three to seven day test stimulation involving the placement of a temporary electrode into the S3 foramen, one on each side, attached to a portable external stimulation device. During this period, all subjects kept a voiding diary and noted their number of incontinent episodes, pads used, and symptoms of urgency, frequency, and nocturia. If at least a 50 Percent improvement was noted, both objectively and subjectively, the subjects were offered a permanent implant. All procedures were done in the operating room and involved the placement of a permanent electrode into the S3 foramen on one side through a small 5–7 cm vertical incision over the sacrum. The electrode body was tunneled under the skin and connected to the stimulating device implanted in the upper buttock through a second horizontal incision. Subjects have been followed for an average of 12.2 months (range 7–16 months).Results: The average age of the subjects was 55.1 years range 30–76 years). All 10 subjects experienced a marked decrease in urge incontinence, urgency, frequency, and nocturia. Eight subjects currently experience no incontinent episodes and are no longer using pads; the other two use only one pad per day. All were using at least four pads daily prior to the implant. All now describe their urgency as “appropriate”. Pre-implant urgency descriptions included “moderate”, “constant”, and “strong” in two, one, and seven subjects respectively. Frequency in all is at least two hours, and reaches four hours in five subjects. Nine of the subjects voided every hour before the implant. Eight subjects experienced three or more episodes of nocturia before the implant; three now void twice per night, while the rest get up either once or not at all. Interestingly, one subject who also suffered from fecal incontinence was cured by this therapy. Another subject with a long history of chronic constipation and an average of one bowel movement per week now moves her bowels daily. All 10 subjects reported satisfaction and responded yes to having this procedure again. There were no adverse effects reported.Conclusions: Sacral nerve stimulation is a promising new therapy for women with intractable urge incontinence and associated urgency, frequency, and nocturia. It appears to be both safe and efficacious. Long term studies with larger numbers of subjects will determine its ultimate place in the management of the overactive bladder. The potential role of sacral nerve stimulation in women with bowel dysfunction and pelvic pain also needs to be investigated.