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Sacral neuromodulation for overactive bladder and pelvic pain

Posted Feb 16 2012 4:11am

This article presents an overview of an innovative treatment for overactive bladderThe organ that stores urine., sacral nerveBundle of fibres that carries information in the form of electrical impulses. stimulation. This new treatment can cure incontinenceThe involuntary passage of urine or faeces. and pelvic pain syndromeLong-standing (over 6 months) pain in the pelvic region, from any cause. Sometimes no specific cause can be identified. without the need for drugs or surgery.

Sacral neuromodulation is a new treatment, which was approved for use in the United Kingdom in 2004, but has only recently been authorised by local authorities and private insurers. Also known as sacral nerve stimulation (SNS) it uses electrical currents to reset the faulty nervesBundles of fibres that carry information in the form of electrical impulses. causing bladder dysfunction.

“Sacral nerve stimulation is a very important breakthrough in the treatment of the overactive bladder and pain syndromes. This new technique provides an effective solution for women when conservative treatment has not worked. It avoids the necessity of repeated treatment with Botox, and the risk of catheters with Botox and major surgery.”

Jeremy Ockrim, Consultant Urologist, University College Hospital and Harley Street, London

Interstim II Sacral Nerve Stimulator

Overactive bladder is a common complaint in women and can affect men too. Bladder spasms cause frequencyApplied to urination, needing to urinate more often than normal, for whatever reason.-urgency and urge incontinenceIncontinence of urine due to abrupt and uncontrollable urges to urinate, if there is insufficient time to reach a bathroom.. Over 30 per cent of women (and 10% of men) will experience problems with continence, typically after childbirth and menopauseThe time of a woman’s life when her ovaries stop releasing an egg (ovum) on a monthly cycle., although younger women can also be affected.

Voiding dysfunction in young women (sometimes called Fowler’s syndrome), is a rare condition resulting in an inability to relax the sphincterA ring of muscle around a natural opening or passage that acts as a valve, regulating inflow or outflow. causing retention of urine and catheter dependence.

The causes of pelvic pain are not well understood and in most cases a specific cause is not identified. Interstitial cystitis is an inflammatory condition of the bladder comparable to arthritisInflammation of one or more joints of the body. of the joints or colitisInflammation of the colon, also sometimes used to mean inflammation of the large intestine generally. of the bowelA common name for the large and/or small intestines.. The condition leads to pain as the bladder fills, resulting in frequency urgency and chronicA disease of long duration generally involving slow changes. pain.

The first step is to have a test procedure to see whether SNS will be effective for you.

The nerves are located in the lower back, adjacent to the sacrumA section of the lower backbone that consists of five vertebrae that are fused together.. Under a short general anaestheticAny agent that reduces or abolishes sensation, affecting the whole body. (or occasionally local anaestheticA medication that reduces sensation in a part of the body.), the surgeon uses a small needle to place a thin wire in contact with your sacral nerves. The other end of the wire is tunnelled under the skin or taped to the back and connected to a temporary stimulator control unit, which is worn on your belt. The temporary stimulator is worn for four weeks to assess your response. The approach works well for approximately 70 per cent of patients.

If you find the treatment effective, you will be asked to come into hospital again to have a permanent implant. This is a much smaller device – the size of a £2 coin – which is implanted under the skin and fatOne of the three main food constituents (with carbohydrate and protein), and the main form in which energy is stored in the body. of the lower back so it cannot be felt. You will not have to have anything attached to your back or any external device. A control unit, the size of a mobile phone, is used to change and control the frequency of electrical signals and you can keep this at home. The infectionInvasion by organisms that may be harmful, for example bacteria or parasites. rate for this procedure is less than 1%.

The procedure is carried out under general anaesthetic, and most patients return home on the same day.

Positioning of nerve stimulator wires and device

This treatment is sometimes referred to as the ‘pacemakerA small electrical device that functions to maintain a normal heart rate. for the bladder’. A traditional cardiacRelating to the heart pacemaker is a device implanted inside the body which sends electrical currents to the heart, correcting faulty heart rhythms.

In an ‘overactive bladder’ the sacral nerves send unwanted messages to the bladder, causing it to contract suddenly (urgency) and empty without due warning (urge incontinence). In voiding dysfunction the reverse happens preventing the sphincter from relaxing. Sacral nerve stimulation works by interrupting this ‘faulty circuit’ and restoring normal communication between the nerves, brain, and bladder. In pelvic and bladder pain the same nerves conduct the pain signals to the brain. Electrical stimulation at the nerve roots dampens these signals and reduces pain in 40–70% of sufferers.

Unlike Botox, there is no need for repeat treatment, and there is little risk of requiring catheters to empty your bladder. The battery in the permanent implant is effective for up to seven years.

Size of Interstim II pacemaker box and remote control (which can be left at home)

The implant is very small and placed underneath the fat of the lower back / upper buttock area. The surgeon makes a small incision of about 3cm to insert the device during surgery, so recovery is quick and straightforward. The device is cushioned by the body’s fat and so you will not be aware that you have any implant in that area although some patients say they are sometimes aware of the device when they lie in certain positions. In 5–10% of patients the device can cause discomfort and its position needs to be adjusted. The electrical stimulation is kept below detectable levels and the patient is not aware of the stimulation unless the pulses are turned up. There is usually an initial period for the first few weeks after the implant is inserted when you are getting used to the device and finding the right level for you.

Sacral nerve stimulation is also used to treat bowel frequency and urgency – a problem that is often associated with overactive bladder. SNS is also reported to help sexual dysfunction and improve sexual sensitivity for women.

Sacral nerve stimulation was first described in 1998 and now has ten years of accumulated evidence establishing its effectiveness and safety. Sacral nerve stimulation was approved by NICE (National Institute for Health and Clinical Excellence) in 2004 and is widely used in Spain, Holland and Germany. However, the technique has not been widely available in the NHS due to cost and limited expertise available in the UK.

To read a patient’s account of their experience of sacral nerve stimulation, click here .

“We have been amazed at our patients’ responses to the new technique. The implant has revolutionised their lives and allowed them to return to social activities, where they had previously lost confidence. We offer continued after care to adjust the device settings according to our patients’ individual needs.”

Julie Jenks, Specialist Nurse Practitioner, University College Hospital, London

Julie Jenks, Specialist Nurse Practitioner, University College Hospital, London

I work alongside Nurse Specialist Julie Jenks and we have the largest experience of sacral nerve stimulation for bladder dysfunction in the UK. I am the lead specialist for SNS and bladder dysfunction at University College Hospital, London. Together we have treated over 140 patients in the last 12 months and have many more waiting; with the majority finding their urgency and incontinence has significantly improved or ceased, and over 70% proceeding to the permanent implant after a test stimulation.

The stimulator runs continuously for up to seven years and will be invisible to everybody. Awareness of the neurostimulator will gradually diminish, and you may not even feel its presence. Sometimes, several visits are necessary to fine tune the settings during the first three months. Otherwise, you may only need a yearly check-up.

Airport screeningA way to identify people who may have a certain condition, among a group of people who may or may not seem to systems can cause the neurostimulator to turn OFF or ON. It does not change your stimulation parameters. Use your patient programmer to switch your neurostimulator to what it was before. To avoid possible problems with airport screening systems, you may want to show your InterStim identification card and ask those in charge to let you bypass the screening device.

There are specific restrictions while carrying out your activities, but you should avoid activities that involve sudden, excessive, or repetitive bending, twisting, bouncing, or stretching especially soon after the surgery. These movements could damage or move your implanted lead or affect the implanted neurostimulator. Usually, movements do not affect the sensation of the stimulation.

1. Herbison GP, Arnold EP. Sacral neuromodulation with implanted devices for urinary storage and voiding dysfunction in adults. Cochrane Database Syst Rev. 2009;15(2):CD004202

2. Van Kerrebroeck et al. Results of Sacral Neuromodulation Therapy for Urinary Voiding Dysfunction: Outcomes of a Prospective, Worldwide Clinical Study. The Journal of Urology. 2007;178:2029-2034

3. Chaabane W et al. Sacral neuromodulation for treating neurogenic bladder dysfunction: clinical and urodynamic study. Neurourology & Urodynamics. 2011;30(4):547-550

4. Gajewski JP, Al-Zahrani AA. The long-term efficacy of sacral neuromodulation in the management of intractable cases of bladder pain syndrome: 14 years of experience in one centre. British Journal of Urology International. 2011;107(8):1258-1264

5. Powell CR, Kreder KJ. Long-term outcomes of urgency-frequency syndrome due to painful bladder syndrome treated with sacral neuromodulation and analysis of failures. The Journal of Urology 2010;183(1):173-176

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