Sacral nerve stimulation during pregnancy in patients with severe fecal incontinence

Abstract

In recent years, sacral nerve stimulation (SNS) has been established as an effective treatment of fecal incontinence (FI) [1]. However, although this pathology affects predominantly women, sometimes those of childbearing age, its effect on the pregnancy is not known. A 28-year-old female, with severe FI following obstetric anal sphincter injury, was treated in our hospital with SNS after unsuccessful previous external anal sphincter repair. The incontinence status classified according to the Wexner score [2] was 19/20 before SNS treatment. A quadripolar electrode (Medtronic Model 3889) was placed under local anesthesia at the right S3 foramen based on the best sensory and motor response during the peripheral neural evaluation and connected via a percutaneous extension kit (Medtronic Model 3550-05) to an external test stimulation (Medtronic Model 3625). After 3 weeks of temporary stimulation, the number of incontinence episodes or days with incontinence decreased by over 50 % and the patient received the permanent stimulation generator (INTERSTIM II, Medtronic Model 3058) subcutaneously placed in a pocket created in the ipsilateral gluteal area. The Wexner score decreased to 0/20 after placement of the permanent stimulation generator. Three years later, the patient became pregnant, and against medical advice, she kept the stimulator activated for FI symptom control during the pregnancy. SNS did not seem to have any adverse effect during pregnancy. The patient had an uncomplicated pregnancy and a fullterm baby boy was delivered via vacuum extraction. After vaginal delivery, the functional results of SNS suddenly worsened. The patient developed passive fecal incontinence and her Wexner score was 16/20. After the amplitude and polarity stimulation were changed, the patient’s symptoms did not improve. An X-ray showed that the electrode was broken and displaced (Fig. 1). A new electrode was successfully implanted under local anesthesia. The patient recovered physiological continence and her Wexner score decreased to 0/20. There was no cessation of clinical response during the follow-up and no complications were observed. The safety of SNS in pregnancy has not been well established and pregnancy still is an exclusion criterion for SNS therapy. It is important to know that there are very few reports of this treatment in the pregnancy. To the best of our knowledge, we report the first case of use of SNS as treatment of FI in pregnancy, with a healthy newborn but with sacral electrode migration during vaginal delivery. Nanninga et al. [3] communicated the use of SNS to reduce bladder hyperreflexia and incontinence in a pregnant woman with myelodysplasia. They did not observe any adverse effects on the woman or during childbirth. El-Khawand et al. [4] reported the case of a 25-year-old woman who had SNS for severe interstitial cystitis and bladder pain syndrome. The woman kept the stimulator activated for symptom control during two pregnancies. Her first child was later diagnosed with chronic motor tic disorder, and the second had a pilonidal sinus at birth. In addition, the efficacy of SNS decreased after each pregnancy. Govaert et al. [5] showed some effect of SNS on uterine activity. In three premenopausal women, SNS seems to P. Moya J.-M. Navarro A. Arroyo A. Lopez J. Ruiz-Tovar R. Calpena Department of Surgery, University General Hospital of Elche, Alicante, Spain