Patient selection for sacral nerve stimulation

[Functional-neurosurgical treatment options for functional pelvic floor disorders : Value of sacral neuromodulation]

BACKGROUND

Sacral neuromodulation is an established minimally invasive therapy indicated for the treatment of functional pelvic floor disorders. While it received its original US Food and Drug Administration (FDA) approval for the treatment of overactive bladder symptoms, it is now regarded as a therapeutic option to treat both urinary/fecal incontinence and retention. In addition, it has proven to be a valuable tool in the treatment of chronic pelvic pain, and preliminary results indicate a potential to elicit improvements in sexual functioning.

OBJECTIVE

This article serves to provide a summary of the therapy and its applications.

METHOD

Selective literature review.

RESULTS

Sacral neuromodulation implants allow for the controlled shifting of the autonomic control of bladder and rectum towards an inhibition or facilitation of voiding, dependent on the patient's needs and under the patient's control. At the same time and depending on the applied stimulation, the implants can interfere with the nerve's conduction of pain signals. This makes them a therapeutic option for pelvic pain that fails to respond to conventional treatment. Finally, there have been first reports suggesting improvements in sexual dysfunction under sacral neuromodulation, thus, potentially opening up a new line of therapy for those disorders.

DISCUSSION

Sacral neuromodulation is a flexible and efficient form of therapy for functional disorders of the pelvic floor. Specifically, the same intervention can treat seemingly contradictory disorders such as urinary/fecal incontinence and retention as well as chronic pain.

Neuromodulation for Restoration of Urinary and Bowel Control

Control of the lower urinary tract is a complex, multilevel process that involves the peripheral and central nervous systems. Patients with spinal cord diseases or injuries present with multiple bladder and bowel problems. The commonest are urinary, urgency, frequency, urge incontinence, retention and/or fecal incontinence. Though the first reports of neurostimulation to empty bladder came in 1970s', it was only in 1988 that Schmidt and Tanagho restarted discussion and application of neuromodulation and electrical stimulation of sacral nerve in urology. In April, 1999 - FDA approved the InterStim System for treatment of symptoms of urgency-frequency and urinary retention. In October 2000, Medtronic Commercial Release for SNS-Bowel was approved. In October 2002, the Tined lead was launched and N'Vision programmer was launched in the official market in Europe. SNM is now considered the third line of management in refractory cases of OAB, chronic NOUR, frequency and urgency. Role in neuropathic bladder is still being assessed. SNM includes a thorough preoperative assessment, PNE (Percutaneous Nerve Evaluation) without any muscle relaxation and finally installation of a permanent IPG after assessing reponse. We have an experience of over 20 patients in last 11 years. These include patients of refractory OAB, chronic NOUR and Cauda Equina Syndrome. We do a two-staged procedure in view of the high cost and abide by the AUA, EAU and ICS guidelines. Our long term results for neuropathic OAB are awaited.

Pelvic pain: a pathway for care developed for both men and women by the British Pain Society

This paper aims to explain the key points and highlight some of the controversies in the development of the British Pain Society's pelvic pain patient pathway map. Many clinicians lack experience and confidence with this group of patients, and this issue is highlighted. Additionally, the difficulties of classification and definitions in this area are discussed in detail. These are historical causes of disagreement among specialists which can lead to confused clinical care. This group of patients have multiple issues that cross many professional boundaries; they are best managed by the co-ordinated involvement of multiple teams. Patients suffer from significant distress and disability that often needs specialist assessment and intervention (interdisciplinary). This suggests that an integrated approach is required across the historic boundaries of primary and secondary care. A variety of interventions, including opioids and neuromodulation are recommended in the pathway and the controversies surrounding these inclusions are aired in detail.