Sacral Spinal Nerve Stimulation Research Articles

Neural pathway of bellows response during SNM treatment revisited: Conclusive evidence for direct efferent motor response.

In sacral neuromodulation (SNM) patients, it is thought the bellows response elicited upon sacral spinal nerve stimulation is reflex-mediated. Therefore the mechanism of action of SNM is considered to be at the spinal or supraspinal level. These ideas need to be challenged. To identify the neural pathway of the bellows response upon sacral spinal nerve stimulation. Single tertiary center, prospective study (December 2017-June 2019) including 29 patients with overactive bladder refractory to first-line treatment. Recording of the pelvic floor muscle response (PFMR) using a camcorder and electromyography (EMG) (intravaginal probe and concentric needles) upon increasing stimulation during lead or implantable pulse generator placement. The lowest stimulation intensity needed to elicit a visual PFMR and electrical PFMR was determined. Electrical PFMRs were subdivided according to their latency. the association between visual and electrical PFMRs. Statistical analyses were performed using the weighted kappa coefficient. Three different electrical PFMRs could be identified by surface and needle EMG, corresponding with a direct efferent motor response (R1), oligosynaptic (R2), and polysynaptic (R3) afferent reflex response. Only the R1 electrical PFMR was perfectly associated with the visual PFMR (κ = 0.900). The visual PFMRs upon sacral spinal nerve stimulation are direct efferent motor responses. A reopening of the discussion on the mechanism of action of SNM is possibly justified.

Sacral Neuromodulation in Children With Urinary and Fecal Incontinence: A Multicenter, Open Label, Randomized, Crossover Study

The clinical benefit of sacral neuromodulation is unclear due to the paucity of randomized trial data. The purpose of this study was to evaluate sacral neuromodulation for management of urinary and fecal incontinence in a pediatric population. This multicenter, open label, randomized, crossover study included children older than 5 years. After trial stimulation of the S3 root a neuromodulator (InterStim) was implanted on the S3 foramen. Clinical examinations, voiding and bowel diaries, and urodynamic and manometric evaluations were performed at the beginning (t1) and end (t2) of the first period, and at the beginning (t3) and end (t4) of the second period. A total of 33 patients (24 boys) with a mean +/- SD age of 12.22 +/- 5.09 years were randomized. Etiologies were mainly of neurological origin. Incontinence was mixed urinary and fecal in 19 cases, urinary only in 9 and fecal only in 5. Cystometric bladder capacity increased during sacral neuromodulation (delta +24.27 ml vs -37.45 ml, p = 0.01). There was no significant change in other urodynamic or manometric parameters. Overall positive response rate was more than 75% for urinary (81%) and bowel (78%) function. Crossover analysis indicated that sacral neuromodulation is more effective than conservative treatment for both types of incontinence (p = 0.001). In a pediatric population sacral neuromodulation is effective for bladder and bowel dysfunction and should be considered before irreversible surgery.

Sacral nerve stimulation for fecal incontinence: What has been achieved: Current status

The indications for sacral nerve stimulation (SNS) for fecal incontinence expanded during the last decade. This report aims to analyse the clinical outcome of the current pragmatic use of sacral nerve stimulation in the treatment of fecal incontinence caused by various pathophysiological conditions. Secondly it intends to explore the most recent use of SNS in patients presenting with sphincteric lesions. The literature was searched using Medline and Cochrane databases. The search was limited to publications in English. For the analysis, studies with less than 25 patients were excluded. For the presentation of SNS in patients with sphincter defects, all papers were included. Thirteen publications were included in the analysis of clinical outcome of SNS. Ten papers were identified reporting about the application of SNS in patients presenting with a morphological sphincter lesion. The most common outcome measures of clinical efficacy were frequency of incontinence and Cleveland Clinic Incontinence Score. All studies demonstrated a highly improved function, in all outcome measures used. The improvement was significant. The results are reproducible. Also in patients with sphincteric gaps ranging form 17 to 180 degree SNS was clinical efficient. The size of the lesion had not impact on the outcome. Sacral spinal nerve stimulation has evolved to become a clinical efficient therapy applicable in a wide spectrum of causes leading to fecal incontinence. It is now considered to be an essential part of the current surgical treatment algorithm for fecal incontinence.

Sacral spinal nerve stimulation for fecal incontinence: A viable therapeutic option for refractory incontinence

Sacral spinal nerve stimulation for fecal incontinence: A viable therapeutic option for refractory incontinence

Faecal Incontinence in the Elderly

Faecal incontinence occurs in up to 10% of community dwelling persons > or = 65 years of age and approximately 50% of nursing home residents. It is a vastly under-reported problem that has a devastating effect on those who experience it as well as their spouses and caregivers. There are three broad categories of faecal incontinence among the elderly: (i) overflow incontinence; (ii) reservoir incontinence; and (iii) rectosphincteric incontinence. The first two can be diagnosed based upon the patient's history and physical examination and the response to dietary and pharmacological interventions. The third is assessed by careful physical examination supplemented by diagnostic tests directed towards evaluation of anorectal continence mechanisms. The most important of these is anorectal manometry, which can be supplemented by studies of structure (anal ultrasonography or pelvic floor magnetic resonance imaging) and neuromuscular function (electromyogram). A variety of therapeutic interventions are employed in patients with rectosphincteric incontinence; these include dietary, behavioural, pharmacological and surgical modalities chosen on the basis of the results of diagnostic testing. For isolated internal anal sphincter weakness, a cotton barrier in the anal canal is often effective. Acute sphincter injury is best treated with sphincteroplasty but, otherwise, surgical procedures are of uncertain benefit. Peripheral neurogenic incontinence may be treated with antidiarrhoeal agents, biofeedback techniques and dietary manipulations. Sacral spinal nerve stimulation is a promising new technique for selected patients with neurogenic faecal incontinence and is currently undergoing testing in the US and Europe. Significant improvement in quality of life can be achieved in most elderly persons with faecal incontinence.

Sacral spinal nerve stimulation for faecal incontinence

The following abstracts of articles from leading journals have been selected on the basis of their importance to the practice of obstetrics and gynecology.

Sacral spinal nerve stimulation for faecal incontinence: multicentre study

In patients with faecal incontinence in whom conservative treatment fails, options are limited for those with a functionally deficient but morphologically intact sphincter. We investigated the effect of sacral nerve stimulation on continence and quality of life. In this multicentre prospective trial, 37 patients underwent a test stimulation period, followed by implantation of a neurostimulator for chronic stimulation in 34. Effect on continence was assessed by daily bowel-habit diaries over a 3-week period and on quality of life by the disease-specific American Society of Colon and Rectal Surgeons (ASCRS) questionnaire and the standard short form health survey questionnaire (SF-36). Every patient served as his or her own control. Frequency of incontinent episodes per week fell (mean 16.4 vs 3.1 and 2.0 at 12 and 24 months; p<0.0001) for both urge and passive incontinence during median follow-up of 23.9 months. Mean number of days per week with incontinent episodes also declined (4.5 vs 1.4 and 1.2 at 12 and 24 months, p<0.0001), as did staining (5.6 vs 2.4 at 12 months; p<0.0001) and pad use (5.9 vs 3.7 at 12 months; p<0.0001). Ability to postpone defecation was enhanced (at 12 months, p<0.0001), and ability to completely empty the bowel was slightly raised during follow-up (at 12 months, p=0.4122). Quality of life improved in all four ASCRS scales (p<0.0001) and in seven of eight SF-36 scales, though only social functioning was significantly improved (p=0.0002). Sacral nerve stimulation greatly improves continence and quality of life in selected patients with morphologically intact or repaired sphincter complex offering a treatment for patients in whom treatment options are limited.

QUALITY OF LIFE ASSESSMENT IN PATIENTS WHO UNDERGO SACRAL NEUROMODULATION IMPLANTATION FOR URGE INCONTINENCE: AN ADDITIONAL TOOL FOR EVALUATING OUTCOME

We investigated the impact of sacral neuromodulation on quality of life and assessed the importance of quality of life for determining the success of sacral neuromodulation in patients with detrusor hyperactivity, including instability and hyperreflexia. We also compared it with parameters documented in a voiding diary. From May 1998 to December 2000, 82 female and 31 male patients 17 to 79 years old (mean age 51.1) with urge incontinence (63), urgency/frequency (5), voiding disturbance (41) and pelvic pain (4) resistant to conservative treatment were enrolled in a national prospective registry after showing a positive response to percutaneous nerve evaluation testing. Of the patients 47 who were 32 to 79 years old (mean age 59.2) with urge incontinence due to detrusor instability and 16 who were 27 to 51 years old (mean age 51.5) with hyperreflexia were asked to complete a validated self-reporting incontinence domain specific quality of life questionnaire before, and 3, 6, 9, 12, 18, 24 and 36 months after implantation. Compared with baseline the quality of life index significantly improved at each followup, which strongly correlated with the decrease in the number of incontinence episodes. Evaluating quality of life may be an additional useful tool for assessing the results of sacral neuromodulation for urge incontinence. Our study confirms that sacral neuromodulation is effective therapy for urge incontinence that can have a positive effect on patient quality of life.

Treatment of Refractory Urge Urinary Incontinence With Sacral Spinal Nerve Stimulation in Multiple Sclerosis Patients

Treatment of Refractory Urge Urinary Incontinence With Sacral Spinal Nerve Stimulation in Multiple Sclerosis Patients

Treatment of Refractory Urge Urinary Incontinence With Sacral Spinal Nerve Stimulation in Multiple Sclerosis Patients

Treatment of Refractory Urge Urinary Incontinence With Sacral Spinal Nerve Stimulation in Multiple Sclerosis Patients

Treatment of refractory urge urinary incontinence with sacral spinal nerve stimulation in multiple sclerosis patients

Urge urinary incontinence in multiple sclerosis patients is usually due to detrusor hyperreflexia. Patients who do not respond to conservative measures such as anticholinergics, with or without clean intermittent catheterisation, are difficult to manage. We applied electrical stimulation to the S3 sacral spinal nerves with the aim of activating afferent somatic nerve fibres. Stimulation of these fibres can inhibit the micturition reflex. An S3 electrode coupled to a subcutaneously placed pulse generator was implanted in four women who had shown a good response during temporary stimulation via a percutaneously placed wire electrode. All patients were followed for at least 2 years. The number of leakage episodes decreased from a mean of 4 to 0.3 per 24 h. Two patients were completely dry. The hyperreflexia disappeared in one, improved in two, and got worse in one patient. The urodynamic result in the last patient may be explained by clinical progression of the multiple sclerosis. Chronic stimulation of the S3 sacral spinal nerve by an implantable neuroprosthesis is a promising treatment option for selected multiple sclerosis patients with refractory urge incontinence.