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Dr. Udaya Kumar, Urology Today, 12/25/12

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Sacral nerve stimulation therapy for the bladder

Patients with overactive bladder symptoms are often treated with drug therapy, which is usually the first option. However, many such patients may not respond adequately to the medical therapy.

There is also a high rate of discontinuation of treatment, especially among the younger population, due to the costs or side effects such as dry mouth or constipation. There are several options available to such patients.

Pelvic floor muscle biofeedback is a behavioral therapy that may be used as an alternative to or complement prescription drugs for overactive bladder symptoms. Alternatively, bladder activity can be altered or modulated using an entirely different approach by stimulating the nerves to the bladder.

Neuromodulation (modulating the nerve supply) of the bladder using InterStim therapy has gained acceptance as an effective means to treat patients who have failed medical management.

InterStim is FDA-approved for overactive bladder that is refractory to drug treatment, urinary retention that is not due to obstruction and bowel incontinence. Many patients who have significant bowel conditions such as fecal incontinence, bowel urgency or even constipation along with urinary symptoms may see an improvement in both conditions.

Before permanent InterStim placement, test evaluation is done to see if the patient would benefit from InterStim neuromodulation.

During the test phase, a temporary lead is placed in the small of the lower back area near the sacral nerves that are located close to the tail bone. The lead is connected to a small external neurostimulator that the patient wears on the waistband like a pager. This neurostimulator generates mild electrical pulses that can be adjusted.

During the test evaluation that usually last for two to three days, the patient tracks his or her symptoms with a voiding diary, which helps determine the response to the treatment. During the evaluation period, the patient may carry on with his or her usual activities.

The temporary leads are removed at the end of the trial period, and the patient and the physician together decide whether to proceed with long-term neurostimulation.

Placement of the long-term or permanent InterStim neurostimulator is very similar to the test lead placement, except that the neurostimulator is surgically placed under the skin of the buttock. With the long-term device, the patient may control the neurostimulator with a hand-held programmer that works like a remote control to adjust the stimulation up or down.

The success rate with InterStim neuromodulation has been reported at 70 percent to 80 percent in several studies. Success is defined as at least a 50 percent reduction in the symptoms. Studies also report a significant improvement in quality of life, decrease in use of pads and cost of alternative treatments and long term benefits. The benefits appear to be greater than those reported by patients treated with medications.

Finally, botulinum toxin or Botox may be injected into the bladder to treat patients who do not respond to other forms of therapy. While the treatment can be very effective, the benefits are short-lived and repeat injections are required. In addition, the injections are not FDA approved and hence not covered by most insurance carriers.

Overactive bladder is a common condition that presents as urinary urgency and involuntary loss of urine or urge incontinence. Behavioral therapy and drugs are often used as first choice but in patients who respond inadequately or have side effects, sacral nerve stimulation with InterStim can offer lasting benefits.

Udaya Kumar. M.D., FRCS Urol, Dip. Urol (London), is certified by the American Board of Urology and the Board of Urology of U.K. and Ireland. He is a former professor of urology with University of Arkansas for Medical Sciences. Contact him at 3475 S. Suncoast Blvd., Homosassa, FL 34448 or 352-628-7671.