Sacral Nerve Stimulation For Treatment Research Articles

Sacral nerve stimulation for refractory OAB and idiopathic urinary retention: Can phenotyping improve the outcome for patients: ICI-RS 2019?

Sacral nerve stimulation (SNS) is widely used to treat refractory idiopathic overactive bladder (OAB) and idiopathic urinary retention. However, clinical outcomes are variable and understanding predictive factors for success or side-effects would enable personalization of therapy and optimization of outcomes. At the International Consultation on Incontinence-Research Society meeting 2019, a Think Tank was convened to discuss how advances in the basic science study of SNS may be translatable into clinical practice to improve outcomes of patients undergoing SNS treatment. We conducted a literature review and expert consensus meeting focusing on current methods of phenotyping patients and specifically, how advances in basic science research of the mechanism of action of SNS can be translated into clinical practice to improve patient selection for therapy. The terms "Idiopathic OAB" and "idiopathic urinary retention" encompass several underlying pathophysiological phenotypes. Commonly, phenotyping is based on clinical and urodynamic factors. Animal studies have demonstrated that high-frequency stimulation can produce rapid onset, reversible conduction block in peripheral nerves. Altering stimulation parameters may potentially enable personalization of therapy depending upon the clinical indication in the future. Similarly, advances in conditional and closed-loop stimulation may offer greater efficacy for certain patients. Phenotyping based on psychological comorbidity requires further study to potentially optimize patient selection for therapy. Idiopathic OAB and idiopathic urinary retention are heterogenous conditions with multiple potential underlying phenotypes. Tailoring stimulation parameters to the needs of each individual according to phenotype could optimize outcomes. Assessing psychological comorbidity may improve patient selection. Areas for further research are proposed.

A Pilot Study of Non-invasive Sacral Nerve Stimulation in Treatment of Constipation in Childhood and Adolescence.

Background/Aims: Constipation shows both, a high prevalence and a significant impact. However, it is often perceived as minor and treatment choices are limited. The neuromodulation approach is a valuable option to be considered. This study assesses the use of non-invasive sacral nerve stimulation to reduce constipation in children.Methods: Between February 2013 and May 2015, pediatric patients with chronic constipation were treated with this non-invasive neuromodulation procedure, adapted from classical sacral nerve stimulation. A stimulation device attached to adhesive electrodes on the lower abdomen and back generated an electrical field with a stable frequency of 15 Hz via variable stimulation intensity (1–10 V). The effect of therapy was evaluated in routine check-ups and by specialized questionnaires.Results: The study assessed non-invasive sacral nerve stimulation in 17 patients (9 boys, 8 girls, mean age 6.5 years). They underwent stimulation with 6–9 V for a mean of 11 h per day (range 0.5–24 h) over a mean of 12.7 weeks. Improvement of constipation was achieved in more than half of the patients (12/17) and sustained in almost half of these patients (5/12). Complications were minor (skin irritation, electrode dislocation).Conclusions: Non-invasive sacral nerve stimulation appears to be effective in achieving improvement in pediatric patients with chronic constipation. As an additional external neuromodulation concept, this stimulation may represent a relevant addition to currently available therapeutic options. Further studies are needed to confirm these results.

Outcomes of Sacral Nerve Stimulation for Treatment of Refractory Overactive Bladder Among Octogenarians

Sacral nerve stimulation (SNS) is an effective treatment for refractory overactive bladder (OAB). However, advanced age is often cited as a reason to avoid SNS in the elderly. This study evaluates the safety and efficacy of SNS for refractory OAB among our octogenarian population. A retrospective review from a single institution was performed on all SNS lead placements from December 1998 to June 2017 for refractory OAB. Octogenarians were characterized as 80 years of age or older at the time of Stage I. Efficacy and safety were determined by the rate of progression to Stage II, subsequent need for multimodal therapy, and rate of surgical revision and explantation. All patients were followed for a minimum of 12 months. Of 374 patients in this study, 37 (9.9%) were octogenarians. There was no difference in gender, race, smoking history, or prior OAB treatment regimens between cohorts. The rate of progression to Stage II was 56.8% for octogenarians compared to 60.5% for nonoctogenarians (p = 0.66). The rate of surgical revision, explantation, and need for multimodal therapy did not differ between groups. Subgroup analysis of octogenarians did not reveal any significant differences between successful and nonsuccessful Stage I patients. The safety and efficacy of SNS was similar between cohorts. This result suggests that SNS is a safe and effective therapy that should be considered among the treatment options for refractory OAB in octogenarian patients. Further studies are needed to determine predictive factors of Stage I success in elderly patients.

A randomized double-blinded sham-controlled cross-over trial of tined-lead sacral nerve stimulation testing for chronic constipation.

Sacral nerve stimulation (SNS) may provide long-term symptom relief to patients suffering from chronic constipation. Patients are currently selected for SNS using a 2-week peripheral nerve evaluation (PNE) comprising stimulation by temporary leads. However, only 40% of test responders receive long-term benefit from treatment meaning that healthcare costs per successfully treated patient are too high. The primary objective was to assess tined-lead testing to predict benefit from SNS for chronic constipation. A randomized double-blind sham-controlled cross-over design evaluated enhanced PNE (ePNE) using tined quadripolar electrode leads over 6 weeks. The design differentiated between patients with discriminate and indiscriminate responses to testing. A score improvement of 25% or more was considered to be a positive response within a stimulation period. The primary outcome was the proportion of patients showing a reduction of at least 0.5 in constipation symptom score at 6 months. A total of 45 patients were randomized, of whom 29 (64.4%) were test-phase responders. Of these, 27 were implanted providing permanent SNS. During ePNE, seven (18%) were discriminate responders, 22 (56%) were indiscriminate responders and 10 (26%) were nonresponders. Six patients were withdrawn during the test phase because of infection or noncompliance. At 6 months, there was no significant difference in primary outcome between discriminate and indiscriminate responders (60 vs. 57%, P=0.76). The study was terminated prematurely because of a persistent infection rate of 10 (22%) during ePNE of which nine (20%) were severe. ePNE is a poor predictor of treatment response at 6 months. This suggests a strong and persistent placebo response during both SNS PNE and treatment. An extended 6-week PNE poses a high risk of infection.

The Use of Sacral Nerve Stimulation in Treatment of Rectal Incontinence: A Rare Case Report

Rectal incontinence is the involuntary loss of solid or liquid feces and flatus. First step is to avoid foods with high quantities of fructose, lactose, and caffeine. Bulking agents like methylcellulose and antidiarrheal agents like loperamide are tried next to reduce stool consistency and frequency. If symptoms continue and anorectal manometry shows a weak anal sphincter, biofeedback therapy can be tried. Originally a treatment option for urinary incontinence and overactive bladder, minimally invasive sacral nerve stimulation (SNS) is now considered a therapeutic option in refractory rectal incontinence and has shown to provide relief of symptoms and have positive effects on quality of life. Presented is a case of a 79-year-old female with unresolved history of rectal incontinence since 2015. The initial symptom was minimal anal leakage while doing leisure activities such as gardening and shopping. She noted gradual increase in symptoms affecting daily life and causing social embarrassment, which forced her to wear diapers to disguise odor and staining. Diet change, bulking agents, and more recently, anal sphincteroplasty in 2017, failed to improve symptoms. She was warned that anal sphincteroplasty may not be effective due to her three vaginal deliveries and weak pelvic muscle function. Physical exam revealed incontinence during Valsalva. Digital rectal examination revealed weak pelvic muscles and poor anal tone. She has a remote smoking history of half a pack per day between the ages of 22 and 32 and admits to drinking 1-2 glasses of wine daily. She was offered sacral nerve stimulation. A temporary SNS electrode was implanted and she was told to keep a diary of her bowel movements for 4 weeks. She noted improvement and a permanent SNS device was placed. This case illustrates failed attempts of conservative treatments with the patient growing more ambivalent about controlling her symptoms in public. SNS is reserved for patients whose previous treatments have failed to alleviate symptoms. It involves placement of an electrode into the sacral foramen that sends low-grade electrical stimulations to the sacral nerve roots that innervate the anal sphincters and muscle wall. If a trial period with the temporary electrode relieves fecal incontinence, a permanent electrode is placed. It is because of the relationship of the anal sphincters and sacral innervation that candidates must have structurally intact anal sphincters for successful outcomes to be achieved.2945 Figure 1. Management Of Bowel Disorders

Outcomes of treatment of faecal incontinence with sacral nerve stimulation – a Finnish multicentre study

The aim of this multicentre study is to report the results of sacral nerve stimulation (SNS) treatment for faecal incontinence (FI) in Finland and determine factors that could influence SNS treatment outcomes. This is a national multicentre study, involving all patients tested for SNS implantation in Finland from 1999 to 2017. Data were collected retrospectively from electronic patient archives and analysed for possible effects on treatment outcome. Of the 432 patients with FI tested for SNS, 365 were women. Three hundred and thirteen (72.5%) of the tested patients advanced to permanent implantation of a stimulator. A successful final treatment outcome, with subjective alleviation of FI, was reported by 59.3% of the patients at the end of follow-up (mean 2.4 years, range 8 days to 13.3 years). Patients with obstetric sphincter injury and idiopathic FI had more permanent stimulator implantations than patients with iatrogenic injury (P = 0.012). Male patients had significantly worse test phase outcomes than female patients (P < 0.001). Age did not influence treatment outcome (P = 0.446) CONCLUSION: Subjective final success of SNS treatment for FI was achieved in 59.3% of patients at a mean of 2.4 years. Gender and the aetiology of FI influenced the test phase and final treatment outcome of SNS treatment.

SNS Retention Rates in the Treatment of Refractory OAB, Urinary Retention, and Idiopathic Fecal Incontinence [7G

INTRODUCTION: Sacral nerve stimulation (SNS) has proven to be an effective treatment of refractory overactive bladder (OAB), urinary retention, and idiopathic fecal incontinence. Many studies assessing the effectiveness of this treatment, however, often focus on the short- to medium-term effectiveness (less than 24 months) with a few studies extending up to five years. The purpose of this study is to determine whether patients continue to retain SNS 5 years after implantation. METHODS: This study was performed using health insurance claims data from Clinformatics DataMart. Data were collected between January 1st, 2002 and September 30th, 2014. Diagnoses and procedures were identified based on International Classification of Diseases, Ninth Revision, Clinical Modification and Current Procedural Terminology codes. Data were initially screened for patients who had completed SNS implantation (n=2248). Inclusion criteria included women aged 18-65 who had had continuous insurance enrollment in the prior year (n=1231). Patients were excluded if they had had procedures associated with SNS treatment in the prior year (n=884). For each year, we assessed the number of patients who still had the SNS implant compared to the number of patients who had the SNS implant removed during follow-up. RESULTS: At year one, 85.8% of patients had retained the SNS implant (549/640). At year two, 81.4% (341/419). At year three, 78.1% (210/269). At year four, 79.0% (124/157). And at year five, 72.0% (67/93). CONCLUSION: The retention rate for SNS as a treatment for refractory OAB, urinary retention, and idiopathic fecal incontinence continues to be high at five years follow-up.

1127 Sacral Nerve Stimulation for Treatment of Constipation in Children: Long-Term Outcomes, Patient Benefit, and Parent Satisfaction

1127 Sacral Nerve Stimulation for Treatment of Constipation in Children: Long-Term Outcomes, Patient Benefit, and Parent Satisfaction

Sacral nerve stimulation--hidden costs (uncovered).

The aim of this study is to determine the occurrence of surgical revision in a cohort of patients treated with sacral nerve stimulation (SNS) for faecal incontinence and constipation and to establish the types of procedures performed and indications for surgery. From the years 2002 to 2014, 125 patients were identified who had undergone permanent SNS therapy with 36 (28.8%) patients requiring surgical intervention postimplantation. These cases were retrospectively reviewed (range of follow-up 1-99months). Over a total of 1512months of SNS treatment, 51 unplanned surgical procedures were required in 36 patients. At present, 48 procedures have been performed at an average of 2.6years following implantation and three patients are awaiting surgery. Lead-related problems accounted for 30 (58.8%) procedures at an average of 1.7years affecting 22 patients. Battery and implantable pulse generator-related problems attributed to 13 procedures (25.5%) in 12 patients at an average of 5.0years. Battery depletion occurred in seven patients at an average of 5.4years. Surgical revision was required to replace, remove, or resite various components of the SNS system. Indications for surgery included lead damage, pain and loss or lack of SNS efficacy. Explantation was warranted in six patients due to poor SNS efficacy, pain, infection and facilitation of a magnetic resonance imaging scan. This was performed at an average of 1.6years. A considerable proportion of patients treated with SNS therapy require surgical revision. These unplanned procedures are associated with substantial unexpected costs that financially burden SNS services.

Cost-effectiveness analysis of sacral nerve stimulation as treatment for severe irritable bowel syndrome.

Early results from sacral nerve stimulation (SNS) for severe irritable bowel syndrome (IBS) are promising but estimates of cost-effectiveness are lacking. Our object was to perform a cost-effectiveness analysis for SNS as an alternative to no treatment of IBS. This retrospective analysis was based on the results from a randomized controlled crossover study with a cost-utility analysis performed on patient-level data and modelling of censored data over a projected period of time of up to 20years. The analysis was conducted on an intention-to-treat approach. For estimation of the uncertainty of the incremental cost-effectiveness ratio a bias corrected bootstrap analysis was performed. Cost-effectiveness was not reached for 4years after permanent implantation (£31270 per quality-adjusted life years), which was the upper limit for patient follow-up, but our data imply a cost-effectiveness from a 7-year perspective onwards. The study indicates the SNS treatment for IBS is cost effective from a 7-year perspective onwards.

Is Permanent Sacral nerve Stimulation Implantation Under Local Anaesthesia Feasible and Effective?

Background: Sacral nerve stimulation (SNS) is a minimally invasive surgical technique that plays an important role in the treatment of disorders of the bladder and bowel. Permanent SNS implantation under local anaesthesia (LA) offers many advantages. Objectives: To assess if implantation of permanent sacral nerve stimulation (SNS) under local anaesthesia (LA) is feasible and effective. Patients and Methods: Using a prospective database, nine patients who had permanent SNS implantation under LA in our unit were selected and analysed. Results: Four patients suffered from underlying cardiovascular disease and LA was deemed more appropriate to minimise perioperative risks. The decision to opt for LA in the other five patients was indicated due to patient preference. The average volume of lignocaine 1% used was 25 millilitres and operative length of time was 36 minutes, with the lead inserted into the right S3 foramen in all patients. Eight patients were discharged on the day of the procedure. Long term follow up revealed that SNS alleviated the symptoms in the majority of the patients, but the benefit gained fluctuated over time. Surgical revision was required in three of these patients, these included replacement of a lead, resiting of the implantable pulse generator, and explantation of the SNS device. Conclusions: Implantation of permanent SNS under LA is a viable surgical option, associated with several advantages that apply to both patients and service provision. Performing this surgical procedure under LA avoids the perioperative risks involved with (general anaesthesia) GA and also offers the possibility of SNS treatment for patients in whom GA is medically contraindicated, ultimately widening the breadth of the cohort suitable for SNS treatment. Other potential benefits include reduction in time and costs involved in carrying out the surgery.

Effects of sacral nerve stimulation on postpartum urinary retention-related changes in rat bladder

ObjectiveTo examine the effect of sacral nerve stimulation (SNS) on the urodynamic function and molecular structure of bladders in rats following acute urinary retention (AUR) after parturition. Material and methodsThirty primiparous rats were divided into three groups: postpartum, postpartum+AUR, and postpartum+AUR+SNS. AUR was achieved by clamping the distal urethra of a rat for 60 minutes. The postpartum+AUR+SNS group received electrical stimulation 60 minutes daily for 3 days after AUR. In addition to cystometric studies and external urethral sphincter electromyography, the expression of caveolins and nerve growth factor (NGF) and caveolae number in bladder muscle were analyzed. ResultsThe postpartum+AUR group has significantly greater residual volume than the postpartum group, but the residual volume decreased significantly after SNS treatment. The postpartum+AUR group had significantly lower peak voiding pressure, a longer bursting period and lower amplitude of electromyograms of external urethral sphincter activity than the postpartum and postpartum+AUR+SNS groups. The postpartum+AUR rats had higher NGF expression, lower caveolin-1 expression, and fewer caveolae in bladder muscle compared with the postpartum rats. Conversely, the caveolin-1 expression and caveolae number increased, and the NGF expression decreased after SNS treatment. ConclusionBladder dysfunction after parturition in a rat model caused by AUR may be restored to the non-AUR structural and functional level after SNS treatment.

PTU-169 Comparison between sphincteroplasty and sacral nerve stimulation for treat-ment of anal incontinence patients with sphincter injuries

<h3>Introduction</h3> This study aimed to compare outcomes of patients with anal sphincter defects treated by sacral nerve stimulation (SNS) or sphincteroplasty (SP). <h3>Method</h3> After IRB approval, patients treated for FI with a sphincter defect were identified from a prospective database; treatment groups were matched and stratified by SNS or SP. Primary outcome was change in Wexner FI Score (FIS). Demographic variables, past medical history and complication rates were also reviewed. Sphincter defects were assessed by endoanal ultrasound and ranged from 45°–180°. Continuous variables were compared with independent t-tests or Mann-Whitney U tests based on evidence of Gaussian distribution. Categorical variables were compared with Chi-squared analyses. Paired within group analyses were performed with paired t-tests and Wilcoxon signed-rank test. In order to perform a paired assessment of the role of each intervention in affecting the FIS, an Analysis of Covariance (ANCOVA) was performed. <h3>Results</h3> 26 female patients were included, 13 each underwent sphincteroplasty or SNS. The groups were similar with regards to age (62.2 vs 57.2 years, p = 0.16), BMI (26.2 vs 26.5, p = 0.33), initial FIS (15.9 vs 16.8, p = 0.39) and follow-up (14 vs 10 months, p = 0.72). The groups were similar for &gt;1 vaginal delivery or rates of urinary incontinence (p = 1.00 and p = 0.62, respectively). Early postoperative complications included 1 patient in each group with wound infection. Within group analyses revealed a significant improvement of FIS in SNS patients (15.9 to 8.4; p = 0.003) but not observed in the SP group (16.9 to 12.9; p = 0.078). Between groups, a trend towards lower FIS was seen in the SNS group as compared to SP but was not significant (8.4 vs 12.9; p = 0.06). ANCOVA analysis did reveal either procedure as superior in reducing FIS. <h3>Conclusion</h3> This study demonstrates that within each group SNS is effective at reducing FI in patients with a sphincter defect. Larger sample sizes will be required to better compare the difference in scores and assess for superiority between procedures. <h3>Disclosure of interest</h3> None Declared.

Electromagnetic tracking of needle intervention for sacral nerve stimulation using the image-guided surgery toolkit (IGSTK)

Sacral nerve stimulation (SNS) is a therapeutic medical procedure that stimulates the sacral nerve using an electrode inserted near the sacral nerve to treat the conditions of overactive bladder and fecal incontinence. The primary challenge in the SNS procedure is that the physician inserts a needle to place an electrode through the narrow structure of the sacrum while relying on fluoroscopic images. We developed a navigation system which relies on an off-the-shelf electromagnetic tracking device, preoperative CT images, and a graphical user interface for needle insertion. Subjects inserted the needle into targets in a free metallic environment and in a surgical environment with a sacral phantom model. The mean registration error in four trials was 0.90±0.081 mm in the free metallic environment and 1.16±0.49 mm in the surgical environment. The mean user error (UE) between the needle tip position and a target was 5.08±1.27 mm in the free metallic environment and 4.26±2.87 mm in the surgical environment. We believe that our navigation system has potential to improve clinical sacral nerve stimulation treatment considerably. To support clinical application of this method, several remaining issues pertaining to the developed navigation system in an in vivo environment must be resolved.

Sacral Neuromodulation in Patients with Idiopathic Overactive Bladder after Initial Botulinum Toxin Therapy

We evaluated whether patients with overactive bladder and incontinence who discontinued intravesical botulinum toxin therapy can be successfully treated with sacral neuromodulation. All patients who were referred to our center after discontinuation of botulinum toxin-A between 2005 and 2010 were included in this observational study. All patients underwent test stimulation with sacral neuromodulation and were evaluated with voiding diaries. Success was defined as more than 50% improvement in leakage episodes. Successful test stimulation was subsequently followed by a definitive implant. Patient satisfaction with sacral neuromodulation therapy was evaluated 1 year after the definitive implant. A total of 20 patients were included in the study. Of these patients 17(85%) had discontinued botulinum toxin-A because of lack of efficacy and 3had been treated successfully with botulinum toxin-A but requested a more permanent solution. The mean interval between the botulinum toxin-A and the sacral neuromodulation test stimulation was 23 months. In 14 patients (70%) thetest stimulation was successful and they received a definitive implant. Of the 14patients 5 even showed a decrease of greater than 90% in leakage episodes. One year after implantation 11 patients (79%) were satisfied with the sacral neuromodulation treatment. Despite the small sample size, this study indicates that patients who are dissatisfied with or in whom botulinum toxin-A treatment fails can respond successfully to sacral neuromodulation. The success rate of the test stimulation was comparable to that of patients who have never been treated with botulinum toxin-A. The 1-year satisfaction rate was comparable that of patients without a history of botulinum toxin-A treatment.

Transcutaneous Parasacral Electrical Neural Stimulation in Children with Primary Monosymptomatic Enuresis: A Prospective Randomized Clinical Trial

Parasacral transcutaneous electrical neural stimulation is widely used to treat hyperactive bladder in children and adults. Its use in nonmonosymptomatic enuresis has demonstrated improvement in number of dry nights. We assessed the effectiveness of parasacral transcutaneous electrical neural stimulation in the treatment of monosymptomatic primary enuresis. This prospective randomized clinical trial included 29 girls and 16 boys older than 6 years with primary monosymptomatic enuresis. Children were randomly divided into 2 groups consisting of controls, who were treated with behavioral therapy, and an experimental group, who were treated with behavioral therapy plus 10 sessions of parasacral transcutaneous electrical neural stimulation. Neural stimulation was performed with the electrodes placed in the sacral region (S2/S3). Sessions always followed the same pattern, with duration of 20 minutes, frequency of 10 Hz, a generated pulse of 700 μs and intensity determined by the sensitivity threshold of the child. Sessions were done 3 times weekly on alternate days. Patients in both groups were followed at 2-week intervals for the first month and then monthly for 6 consecutive months. Rate of wet nights was 77% in controls and 78.3% in the experimental group at onset of treatment (p = 0.82), and 49.5% and 31.2%, respectively, at the end of treatment (p = 0.02). Analyzing the average rate of improvement, there was a significantly greater increase in dry nights in the group undergoing neural stimulation (61.8%) compared to controls (37.3%, p = 0.0038). At the end of treatment percent improvement in children undergoing electrical stimulation had no relation to gender (p = 0.391) or age (p = 0.911). Treatment of primary monosymptomatic enuresis with 10 sessions of parasacral transcutaneous electrical neural stimulation plus behavioral therapy proved to be effective. However, no patient had complete resolution of symptoms.

Percutaneous Tibial Nerve Stimulation for the Long-Term Treatment of Overactive Bladder: 3-Year Results of the STEP Study

We report the long-term efficacy and safety of percutaneous tibial nerve stimulation with the Urgent® PC Neuromodulation System for overactive bladder after 3 years of therapy. Fifty participants in the randomized, double-blind SUmiT (Sham Effectiveness in Treatment of Overactive Bladder Symptoms) Trial who met the primary effectiveness end point after 12 weekly percutaneous tibial nerve stimulation treatments were enrolled in this prospective study to assess long-term outcomes with percutaneous tibial nerve stimulation. STEP (Sustained Therapeutic Effects of Percutaneous Tibial Nerve Stimulation) Study patients were prescribed a fixed schedule 14-week tapering protocol followed by a personal treatment plan aimed at sustaining overactive bladder symptom improvement. Overactive bladder and quality of life questionnaires were completed every 3 months and 3-day voiding diaries were completed every 6 months. A total of 29 patients completed the 36-month protocol and received a median of 1.1 treatments per month after a 14-week treatment tapering protocol. A Bayesian model estimated that 77% (95% CI 64-90) of patients maintained moderate or marked improvement in overactive bladder symptoms at 3 years. Compared to baseline, median voids per day decreased from 12.0 (IQR 10.3-13.7) to 8.7 (IQR 7.3-11.3), nighttime voids per night decreased from 2.7 (IQR 1.7-3.3) to 1.7 (IQR 1.0-2.7) and urge incontinence episodes per day decreased from 3.3 (IQR 0.7-6.0) to 0.3 (IQR 0.0-1.0) (all p <0.0001). All quality of life parameters remained markedly improved from baseline through 3 years (all p <0.0001). One patient experienced 2 mild treatment related adverse events of bleeding at the needle site during followup. Most STEP participants with an initial positive response to 12 weekly percutaneous tibial nerve stimulation treatments safely sustained overactive bladder symptom improvement to 3 years with an average of 1 treatment per month.

Sacral nerve stimulation treatment in functional anorectal pain

To evaluate the treatment outcomes of sacral nerve stimulation(SNS) for functional anorectal pain(FAP). A total of 32 patients of FAP received SNS treatment through S3 from March 2011 to December 2011. Visual analogue scale(VAS), anal pressure measure, and health survey(SF-36) before and after treatment were used to evaluate the outcomes. After treatment, VAS score was significantly decreased, rectal anal reflex threshold volume elevated, and anal maximum contraction pressure (AMCP) and anal rest pressure significantly decreased compared with those before treatment(all P<0.01). Except for general health, the remaining dimension score of the SF-36 increased significantly after treatment, and the differences were statistically significant(P<0.05 or P<0.01). After SNS treatment, 19 cases were cured, 12 improved, 1 was refractory. The total effective rate was 96.9% during 3 months after treatment. SNS is a safe and effective alternative for FAP and can alleviate the pain symptom and improve the quality of life.

Effect and nursing of sacral nerve stimulation treatment for patients with spastic pelvic floor syndrome

Objective To explore the treating effect and nursing methods of sacral nerve stimulation (SNS) for patients with spastic pelvic floor syndrome (SPFS).Methods 36 cases of patients with SPFS who had received SNS treatment were selected to observe SNS treating effect,summarize SNS nursing measures,and compare patients' clinical symptoms before and after the treatment.Results After a course of SNS treatment,12 cases out of 36 were cured,22 were better,2 were invalid,with the total efficiency rate of 94.4％.The symptoms including defecation incompletion feeling,difficult defecation,anal pain and anal obstruction were much better after the treatment than before,and the differences were statistically significant (x2 =26.972,22.500,56.933,40.500,respectively; P ＜ 0.01).Conclusions SNS has a definite effect on treating SPFS.Psychological nursing before therapy and health education after therapy are the key points for successful treatment. Key words: Treating results; nursing; SNS; SPFS

Sacral nerve stimulation during pregnancy in patients with severe fecal incontinence

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