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PubMed2002

Sacral neuromodulation: new applications in the treatment of female pelvic floor dysfunction.

PURPOSE OF REVIEW: The first sacral nerve stimulators implanted by Tanagho and Schmidt (1981) were performed for the indications of urinary urge incontinence, urgency-frequency, and nonobstructive urinary retention. Since that time, observations have been made for benefits beyond voiding disorders. These additional benefits have included re-establishment of pelvic floor muscle awareness, resolution of pelvic floor muscle tension and pain, decrease in vestibulitis and vulvadynia, decrease in bladder pain (interstitial cystitis), and normalization of bowel function. RECENT FINDINGS: Therapy for fecal incontinence in patients with a structurally intact sphincter mechanism appears to be very promising. Investigators agree that there is a role for sacral nerve stimulation in patients with urge fecal incontinence that have failed conservative efforts. Objective manovolumetric testing shows an increase in resting pressure, an increase in voluntary contraction pressure, a decrease in rectal volumes which cause first urge, a decrease in rectal volume to initiate first urge to defecate, and an increase in duration of maximum squeeze pressure. Intractable interstitial cystitis is defined as patients that have failed conventional therapy. Historically, the only option remaining was extirpative surgery or diversion. Maher et al. reported on patients with intractable interstitial cystitis who had undergone sacral nerve stimulation. They found that 73% of these patients had a reduction in pelvic pain, daytime frequency, nocturnal urgency and an increase in average voided volumes. The final area of interest concerns refractory pelvic pain. Siegal et al. reported a decrease in severity, number of hours of pain, and improved quality of life measures in patients who underwent transforamenal sacral nerve stimulations. These patients had all failed conventional pain therapy. SUMMARY: While the data are encouraging in these new arenas of pelvic floor disorders, investigators acknowledge the need for multicenter, statistically powered studies to evaluate the validity of these findings.

Cystitis, Interstitial↗
PubMed2004

Sacral neuromodulation for refractory detrusor overactivity in women with an artificial urinary sphincter.

PURPOSE: We assessed the efficacy of sacral neuromodulation as an alternative therapeutic option in women with an artificial urinary sphincter (AUS) who had de novo irritative urinary symptoms (urgency/frequency) refractory to conventional treatment. MATERIALS AND METHODS: Between 1984 and 2002 we implanted an AUS in 350 women and detrusor overactivity developed in 14. Six of the 14 patients responding positively to a percutaneous nerve evaluation test (greater than 50% subjective/objective improvement) were implanted with an S3 neuromodulator within 42.8 weeks (range 21 to 106) of AUS implantation. Followup included analysis of the voiding diary, a pad test and urodynamic assessment. RESULTS: After 30.5 months followup (range 14 to 40) 1 patient was dry, 4 were improved and treatment failed in 1. At 12 months mean voiding frequency daily had decreased from 17 (range 12 to 23) to 8 (range 4 to 12) and the mean number of leakages episodes daily had decreased from 14.7 (range 8.5 to 17) to 6 (range 4 to 10). Mean voided volume had increased from 121.7 (range 90 to 170) to 180 ml (range 120 to 225), mean first desire to void volume had increased from 117 (range 88 to 190) to 183 ml (range 130 to 275) and mean functional bladder capacity had increased from 325 (range 200 to 530) to 372 ml (range 250 to 580). Uninhibited bladder contractions had resolved in 4 of 5 patients. CONCLUSIONS: In women who already have an AUS with urge incontinence sacral neuromodulation can help resolve symptoms. Because this therapy does not compromise the potential for future treatment, it appears to be an alternative option in these patients. It can postpone or avoid more mutilating surgery and self-catheterization.

Adult↗
PubMed1976

Mechanosensitive afferent units in the hypogastric nerve of the cat.

1. Recordings have been made from ninety single afferent units in the hypogastric and lumbar splanchnic nerves of the cat. 2. The majority of units examined had properties similar to those previously described in the splanchnic nerve: they were slowly adapting mechanoreceptors with one to six punctate mechanosensitive sites distributed mainly along blood vessels as they approached the viscera in peritoneal ligaments; they had a wide range of mechanical thresholds and conduction velocities in the range 0.5-24 m s-1. 3. Receptive fields were found over the bladder base or its peritoneal ligaments or both, on the uterus or broad ligament or both, on the colon or mesocolon or both, and in association with the ureter, vas deferens, prostate or pelvic fat pads. 4. Discharges from afferent units associated with the bladder were investigated during spontaneous (or reflex) bladder contractions, passive distensions, and tetanic contractions induced by electrical stimulation of the sacral spinal cord. The mean spike rates of the adapted (tonic) discharges, observed during distensions and induced tetani, differed over part of the range of intravesical pressures examined. Their behaviour is discussed in relation to the concept of 'in series' tension receptors within the bladder wall.

Action Potentials↗
PubMed1983

Contralateral termination of primary afferent axons in the sacral and caudal segments of the cat, as studied by anterograde transport of horseradish peroxidase.

Contralateral termination of primary afferent axons in the sacral and caudal segments was studied with the anterograde horseradish peroxidase technique in the cat. The distribution of terminals and branching pattern of terminal fibers were examined on sections incubated in a diaminobenzidine-cobalt chloride medium. The crossed primary afferent axons passing in the dorsal commissure projected to (1) the dorsal gray commissure, (2) small, dorsomedial and ventrolateral parts of laminae III and IV, (3) lamina I, and (4) the Xth area (region dorsal to and around the central canal). In the dorsal gray commissure primary afferent axons formed a dense plexus after taking a tortuous course in mediolateral and rostrocaudal directions. Single axons terminated on both sides, but rarely did they extend outside of this region. The axons terminating in the dorsomedial and ventrolateral parts of laminae III and IV passed through the dorsal gray commissure without giving off collaterals. After reaching laminae III and IV they ascended and/or descended within these laminae and terminated at more rostral or caudal levels. The crossed primary afferent axons passing in the ventral commissure terminated in lamina VIII of the contralateral ventral horn. Some axons terminated in a region ventral to the central canal, and on both sides of lamina VIII.

Afferent Pathways↗
PubMed2000

Distribution and origin of secretoneurin-immunoreactive nerves in the female rat uterus.

Secretoneurin is a 33-amino acid peptide derived from secretogranin II. Secretoneurin immunoreactivity has been localized in the peripheral nervous system where it exerts potent chemotactic activity for monocytes and may play a role in inflammation. Secretoneurin could play a role in this process, although the presence and distribution of secretoneurin-immunoreactive neurons in the female reproductive system has not been documented. Thus, this study was undertaken to examine secretoneurin immunoreactivity in nerves of the rat uterus and uterine cervix. A moderate plexus of secretoneurin-immunoreactive nerve fibers was present in the myometrium and endometrium of the uterus as well as in the smooth muscle and endocervix of the cervix. Many of these fibers were associated with the vasculature as well as the myometrium. Secretoneurin immunoreactivity was present in small- to medium-sized neurons of dorsal root and nodose ganglia. Retrograde tracing with FluoroGold indicated that some of these sensory neurons project axons to the cervix and uterine horns. Secretoneurin-immunoreactive terminal-like structures were associated with neurons in the sacral parasympathetic nucleus of the lumbosacral spinal cord. In addition, some secretoneurin terminals were apposed to pelvic parasympathetic neurons in the paracervical ganglia that projected axons to the uterus and cervix. Double-immunostaining indicated co-existence of calcitonin gene-related peptide or substance P with secretoneurin in some sensory neurons, in some terminals of the pelvic ganglia, as well as nerve fibers in the uterine horn and cervix. Finally, fibers in the uterus and cervix were depleted of secretoneurin by capsaicin treatment. This study indicates that secretoneurin is present in the uterus in C-afferent nerve fibers whose cell bodies are located in sensory ganglia. Some of these fibers contain both secretoneurin and calcitonin gene-related peptide or substance P. These substances have functions in inflammatory reactions. Further, secretoneurin could influence postganglionic parasympathetic "uterine-related" neurons in the pelvic ganglia and preganglionic parasympathetic neurons in the lumbosacral spinal cord.

Animals↗
PubMed2000

Neurostimulation for lower urinary tract voiding problems.

In 1981, Tanagho and Schmidt introduced chronic electrical stimulation of the sacral spinal nerves using a permanently implanted sacral foramen electrode and a battery-powered pulse generator for treatment of different kinds of lower urinary tract dysfunction, refractory to conservative treatment. At our department, chronic unilateral electrical stimulation of the S3 sacral spinal nerve has been used for treatment of vesicourethral dysfunction in 55 patients with a mean postoperative follow-up of 44.3 months. Lasting symptomatic improvement of more than 50% was achieved in 16 of 21 patients with motor urge incontinence (76.2%) and in 22 of the 28 patients with urinary retention (78.6%). In our opinion, chronic sacral neuromodulation offers a sustained therapeutic effect to treatment responders that is not achieved by temporary neuromodulation techniques. Chronic neuromodulation should be considered predominantly in patients with urinary retention and in patients with motor urge incontinence who refuse temporary techniques or who require too much effort to achieve a sustained clinical effect.

Electric Stimulation Therapy↗
PubMed1997

The efficacy and complications of laparoscopic presacral neurectomy in pelvic pain.

OBJECTIVE: To evaluate the efficacy and complications of laparoscopic presacral neurectomy in pelvic pain. METHODS: We reviewed records of 655 patients receiving laparoscopic conservative surgery and laparoscopic presacral neurectomy for diagnoses including adenomyosis with dysmenorrhea (n = 55), moderate and severe endometriosis with dysmenorrhea (n = 127), minimal and mild endometriosis with dysmenorrhea (n = 208), primary dysmenorrhea (n = 99), and chronic pelvic pain with or without pathologic disease (n = 166). Pain relief was evaluated at least 12 months postoperatively. RESULTS: Pain relief was evaluated in 527 patients. Significant pain relief (no pain or mild pain requiring no medication) was found in 22 (52%) of 42 women with adenomyosis, in 75 (73%) of 103 with moderate to severe endometriosis with dysmenorrhea, in 123 (75%) of 164 with minimal to mild endometriosis with dysmenorrhea, in 64 (77%) of 83 with primary dysmenorrhea, and in 84 (62%) of 135 with chronic pelvic pain. There were four major complications (0.6%) that required further surgery, including injury of the right internal iliac artery (n = 1) and chylous ascites (n = 3). Three cases (0.5%) had laceration of the middle sacral vein controlled during laparoscopy. In addition, 485 (74%) of the 655 patients complained of constipation after laparoscopic presacral neurectomy, which was relieved easily by medication. CONCLUSION: Presacral neurectomy can be performed safely and efficiently by laparoscopy and is a valuable alternative treatment for pelvic pain.

Adolescent↗
PubMed2006

Muscle fibrillation as a sign of electrode damage in sacral neuromodulation.

Sacral root neuromodulation is recognized as an effective therapy for chronic voiding dysfunction. However, knowledge about the neuromodulator in the general medical community is scarce. We report a case of muscle fibrillation caused by current leaking from a neuromodulator lead which had been damaged during disc prolapse surgery.

Adult↗
PubMed2001

Perineural cysts presenting as complex adnexal cystic masses on transvaginal sonography.

OBJECTIVE: This study describes the sonographic features of sacral perineural cysts that initially presented as adnexal complex cystic masses on transvaginal sonography. CONCLUSION: Perineural cysts may have a complex cystic appearance, including septation and internal debris, on transvaginal sonography. The extraovarian, extraperitoneal, and posterior location on real-time sonography are suggestive features.

Adnexal Diseases↗
PubMedDate not supplied

[Caudal regression syndrome. Lumbo-sacral agenesis].

Retrospective analysis of six cases of caudal regression syndrome, classified in accordance with vertebral envolvement. The degree of vertebral agenesis, morphology and topography of the conus medularis, neurologic implications (motor, sensitive and autonomous) and associated malformations, of particular importance in some situations of little significant vertebral agenesis are analyzed. Associations with eventual predisponent factors are sought.

Adolescent↗
PubMed2001

Short-term effects of sacral nerve stimulation for idiopathic slow transit constipation.

This study assessed the short-term clinical and physiological effect of continuous sacral nerve stimulation in patients with slow transit constipation. Some patients with idiopathic slow transit constipation are unresponsive to conservative treatments, while colectomy has a variable and poorly predictable outcome. Sacral nerve stimulation is a less invasive and reversible procedure that enables direct neuromodulation of the pelvic floor and hindgut. It has been used successfully in the treatment of urologic disorders and fecal incontinence, and some of these patients with concurrent constipation have also noted improved stool frequency and rectal evacuation. Eight women (median age 47 years, median symptom duration 31 years, median stool frequency once per 6 days) were implanted with a temporary percutaneous stimulating S3 electrode for 3 weeks, attached to an external stimulator (Medtronic, Minneapolis,USA). A bowel symptom diary card, anorectal physiological studies, and a radiopaque marker transit study were completed before and during stimulation. Two patients had cessation or marked diminution of symptoms, including normalization of bowel frequency. Colonic transit did not return to normal in any patient. Rectal sensory threshold to distension was decreased during stimulation. Percutaneous temporary sacral nerve stimulation symptomatically improved a minority of patients with resistant idiopathic slow transit constipation. Sensory function was altered by stimulation. Further studies are required to identify patients who may benefit and to assess a range of stimulation parameters.

Adult↗
PubMed2003

The role of the carbachol test and concomitant diseases in patients with nonobstructive urinary retention undergoing sacral neuromodulation.

The aim of this study was to evaluate the percutaneous nerve evaluation (PNE) test success in patients with nonobstructive urinary retention. A total of 24 PNE tests were performed in patients with nonobstructive urinary retention and in 18 patients, a carbachol test was performed during urodynamics. The diagnosis relating to the acontractile detrusor was also assessed and compared to the outcome of the PNE test. The PNE test was successful in eight of 24 patients (33.3%) with the the highest success rate being observed in patients after hysterectomy (80%). It was successful in five of 12 patients with negative carbachol tests and in three of six patients with positive carbachol tests. We conclude that sacral neuromodulation is an effective treatment option in patients with nonobstructive urinary retention. PNE tests should be performed in all patients with therapy resistant nonobstructive urinary retention, because predictive factors do not exist.

Adult↗
PubMed1988

The effect of sacral nerve stimulation for bladder control during pregnancy: a case report.

Neural stimulation was used to reduce bladder hyperreflexia and incontinence in a woman with myelodysplasia. The stimulation was delivered via an electrode placed in a sacral foramen and attached to a stimulator placed subcutaneously. The patient activated the device to inhibit the bladder and deactivated it to allow voiding. The device proved to be helpful in reducing bladder hyperreflexia and its use during pregnancy did not seem to have any adverse effect.

Adult↗
PubMedDate not supplied

[Effect of sacral roots block in the prostatic structure of the rat].

OBJECTIVE: To validate a simplified model of neural manipulation of the lower urinary tract of the rat, by means of alcoholic blockade of sacral roots. MATERIAL AND METHODS: Twenty Sprague-Dawle rats (aged 3 months) underwent alcohol sacral root blockade under total anesthesia with previous needle placement monitoring (electrostimulation). After 28-30 days, ipsilateral ventral prostatic lobe (VL) was obtained. Macroscopic and light microscopy (LM) studies were performed (computerized image analysis). Results were compared with 20 LV from non manipulated rats. RESULTS: A slight non significant decrease of LV weight in the blockade group was notice. LM study showed a reduced epithelial height after manipulation. Gland compartment mean proportions were: control group: 28.1% (epithelial), 29.8% (stromal), y 70.2% (glandular -lumen plus epithelium-); study group: 30.5% (not significant), 37.4% y 62.3% (both p < 0.05) respectively. Epithelium area did not suffer any variation. A reduced vascular overall count was noted in the study group. Ipsilateral diffusion of blockade solution was shown in 9 rats (45%), and bilateral in 11 (55%). CONCLUSIONS: Alcoholic sacral root blockade produces an atrophy of the glandular component (due to luminal shrinkage, without epithelial change). No differences were found after the macroscopic study. This study could not reproduce the changes produced after standard surgical denervation, therefore we cannot recommend this method to be used in future models.

Animals↗
PubMed1976

Anorectal function after major resections of the sacrum with bilateral or unilateral sacrifice of sacral nerves.

The anorectal function in 3 patients with bilateral and 4 patients with unilateral well-defined loss of sacral nerves after radical tumour excision was studied by clinical examination and by simultaneous registration of the following variables: volume and pressure in the rectum, pressure in the internal anal sphincter area and myoelectrical activity in the external anal sphincter. The patients with bilateral loss of sacral nerves had serious impairment of function. Constipation was their only safeguard against incontinence. The preservation of the first and second sacral nerves bilaterally was not sufficient for discrimination between different qualities of rectal contents passing the anal canal. The sensation of rectal distension was also impaired. The reflex pattern of the internal anal sphincter was, however, intact. The external anal sphincter displayed a weak spontaneous myoelectrical activity in the patients who had at least one second sacral nerve intact, and a weak increase of the activity could be induced voluntarily. The normal transient increase of myoelectrical discharge from the external anal sphincter in response to rectal distension could not, however, be elicited. In patients with total unilateral loss of the sacral nerves no significant impairment of anorectal function was noted. Total one-sided denervation implied deficient sensibility of the anal canal unilaterally, but no disturbance of sphincter function as judged from the reflex response of the internal and external anal sphincters to rectal distension.

Adult↗
PubMed1978

Re-evaluation of differential sacral rhizotomy for neurological bladder disease.

The authors describe long-term follow-up results (4 to 6 years) in 13 patients who underwent differential sacral rhizotomy for urgency incontinence. Six patients were originally presented in a preliminary report in 1973. In the last seven patients, a highly selective rhizotomy of sacral fascicles innervating only the urinary bladder was performed. Results in the original six patients appear to be superior to those in patients who underwent a more refined rhizotomy. Possible explanations for this as well as alternative approaches to the treatment of urgency incontinence are briefly discussed.

Animals↗
PubMed1978

Bladder and urethral responses to isolated sacral motor root stimulation.

After complete intradural lumbosacral rhizotomy and cord transection in 40 cats, parasympathetic discharge was induced by electrical stimulation of the second and third sacral roots. Isolation of the stimulus to the preganglionic motor fiber resulted in bladder contraction and reciprocal urethral pressure loss. The threshold for the urethral response was lower than that of the bladder and the urethral response findings strongly suggest that urethral adrenoreceptor activity can be modified peripherally by a primary parasympathetic stimulus.

Animals↗
PubMed2005

Sacral versus pudendal nerve stimulation for voiding dysfunction: a prospective, single-blinded, randomized, crossover trial.

AIMS: The objective of the study was to compare sacral nerve stimulation (SNS) to pudendal nerve stimulation (PNS) for voiding dysfunction. METHODS: Thirty subjects with voiding dysfunction had a tined lead placed at S3 and a second electrode implanted at the pudendal nerve via a posterior approach. In a blinded, randomized fashion, each lead was tested for 7 days. Voiding diaries and questionnaires were completed and outcomes monitored. RESULTS: The time to place a sacral lead was 25.85 min, pudendal lead 23.71 min (P = 0.57). Twenty-four of 30 (80%) subjects responded and had a permanent implant placed. PNS was chosen as a superior lead in 79.2%, SNS was superior in 20.8%. The order in which the lead was simulated had no impact on the final lead implanted and no carry over effect was seen. Overall reduction in symptoms was 63% for PNS and 46% for SNS (P = 0.02). On a 7-point scale from markedly worse to markedly better, the pudendal lead was superior to sacral for pelvic pain (P = 0.024), urgency (P = 0.005), frequency (P = 0.007), and bowel function (P = 0.049). Complications were minimal. CONCLUSIONS: This is the first blinded study of sacral versus pudendal stimulation for voiding dysfunction. Successful implantation of a pudendal lead was achieved in all subjects. The majority of subjects chose PNS to be superior to SNS. More patients and longer term data is needed to confirm these promising results.

Adult↗