What Is Sacral Nerve Stimulation?Sacral nerve stimulation is a reversible treatment option for patients who suffer with bowel and bladder conditions that have not responded to conservative treatment options. Conservative treatment options that are commonly utilized for these conditions include medications, diet changes, pelvic floor exercises, and biofeedback training.
Sacral nerve stimulation uses electrical stimulation of the sacral nerves by way of an implantable neurostimulator device that includes a neurostimulator and a lead. The electrical stimulation modulates the nerves that supply the bowels, bladder, urinary, and anal sphincters, as well as the pelvic floor muscles. The frequency and intensity of the electric pulses can be managed through an external programmer by the patient or physician.
How Is Sacral Nerve Stimulation Performed?Once the patient has been identified as a candidate for sacral nerve stimulation, they will begin the sacral nerve stimulation process, which involves two steps. The first step is a test phase, which is followed by the second step that involves device implantation.
During the test phase, the physician places a temporary lead that is connected to a small external test stimulator. The trial period lasts between three and seven days and helps to determine if sacral nerve stimulation will provide long-term benefits to the patient. The benefits of the test period procedure is that it is minimally invasive, can be performed with or without fluoroscopic guidance, it is safe and fully reversible, and can be completed within 30 to 60 minutes. The test phase allows the physician to make an informed decision about whether or not to place a permanent sacral nerve stimulator device. If the patient experiences positive results, they may be considered an ideal candidate for a permanent device.
Prior to the device implantation procedure, a local anesthetic is applied near the sacrum.
The physician then uses bony landmarks or fluoroscopic guidance to insert a foramen needle parallel to the sacral curve. Once proper placement is confirmed, the foramen needle stylet is removed and a directional guide is placed. While the directional guide is held in place, the foramen needle is removed. Incisions are made on either side of the directional guide to allow for the introducer sheath to be placed over the directional guide. Once this is completed, the directional guide is removed. The tined lead is then placed and advanced through the introducer sheath. When proper placement is confirmed, the introducer is removed and the tines are deployed. A pocket is created for the neurostimulator device in the upper buttock region, just under the skin. A tunnel is then created from the lead incision site to the neurostimulator site and the lead is threaded through and connected to the neurostimulator device. The neurostimulator device is then placed in the pocket and the pocket is closed.
The area where the device was implanted may be tender after the procedure, however, this will resolve within a couple of weeks. Activities should be limited for the first three to six weeks after the procedure in order to allow complete healing. After healing has occurred, normal activities can be resumed. Patients may be required to visit their physician a few times over a six-month period to fine-tune the device settings. Once the settings are optimal, patients may need to return for check-ups one or two times per year.
There are various adverse reactions that have been associated with sacral nerve stimulation, including: adverse changes in bowel or bladder function, allergic reactions, uncomfortable changes in stimulation sensation, infection, new pain, pain at the neurostimulator or lead site, bleeding, neurostimulator or lead migration, or nerve injury. Additionally, there may be a problem with the device that could lead to transient electric shock.
Patients with an implanted sacral nerve neurostimulator device should not undergo magnetic resonance imaging or diathermy procedures. Additionally, X-ray and radiation therapy may affect the functioning of the device.
Conditions Related To Sacral Nerve StimulationSacral nerve stimulation can be used to treat various condition related to voiding dysfunction disorders, as well as fecal incontinence, and severe constipation.
Voiding dysfunction is a common problem, and may be idiopathic in nature or may have a distinct cause, such as local genitourinary factors or neurological disease. The most common types of voiding dysfunction are urge incontinence, urinary urgency/frequency syndromes, and urinary retention. Urge incontinence refers to the leakage of urine when an individual gets the urge to urinate. Urinary frequency syndrome refers to having the urge to urinate more than eight times per day. Urinary urgency syndrome refers to failing to be able to delay the need to urinate. Urinary retention refers to the inability to empty the bladder completely.
Patients with voiding dysfunction are usually treated with pharmacologic options, pelvic floor rehabilitation, and intermittent catheterization.
Once these conservative treatment options have been exhausted, these patients are often difficult to treat. However, evidence suggests that sacral nerve stimulation may provide a minimally invasive alternative treatment option to patients who are faced with major surgeries including augmentation enterocystoplasty or urinary diversion.
Fecal incontinence refers to the inability to control bowel movements, which results in the leakage of stool from the rectum. Fecal incontinence can result in a high level of physical and social disability. Studies have shown that permanent sacral nerve stimulation is an effective treatment option for fecal incontinence in patients who have both internal and external sphincter insufficiency.
Constipation refers to bowel movements that are infrequent or hard to pass. Patients who suffer from idiopathic constipation are often resistant to pharmacologic and behavioral therapies. Studies have shown that sacral nerve stimulation is an effective option for the management of patients who have failed to respond to conservative treatment methods.
ConclusionPatients suffering with conditions of the bowel or bladder who are unresponsive to traditional treatments may benefit from sacral nerve stimulation. This minimally invasive procedure involves the implantation of a neurostimulator device and leads. The device delivers small electrical impulses that modulate the nerves of the bowels, bladder, urinary, and anal sphincters, and pelvic floor muscles. Treatment with sacral nerve stimulation can help to manage these conditions by reducing or eliminating symptoms, which in turn may improve the quality of life of these patients.
- Das AK, White MD, Longhurst PA. Sacral nerve stimulation for the management of voiding dysfunction. Rev Urol. 2000;2(1):43-52.
- medscape.com. Sacral Nerve Stimulation. 2015.
- George A, Kalmar K, Panarese A, Dudding T, et al. Long-term outcomes of sacral nerve stimulation for fecal incontinence. Diseases of the Colon & Rectum. 2012;55(3):302-306.
- Kamm MA, Dudding TC, Melenhorst J, Jarrett M, et al. Sacral nerve stimulation for intractable constipation. 2010;59:333-340.
- Malouf AJ, Vaizey CJ, Nicholis RJ, Kamm MA. Permanent sacral nerve stimulation for fecal incontinence. Ann Surg. 2000;232(1):143-148.
- Mellgren A, Wexner S, Coller JA, Devroede G, et al. Long-term efficacy and safety of sacral nerve stimulation for fecal incontinence. Diseases of the Colon & Rectum. 2011;54(9):1065-1075.
- Tjandra JJ, Chan MKY, Yeh CH, Murray-Green C. Sacral nerve stimulation is more effective than optimal medical therapy for severe fecal incontinence: a randomized, controlled study. Diseases of the Colon & Rectum. 2008;51(5):494-502.
- com. VII. Surgical Procedures: Sacral Nerve Stimulation| www.urologymatch.com. 2015.