Sacral Neuromodulation (Bladder Stimulator)
- What Is Sacral Neuromodulation (Bladder Pacemaker)?
- What Does Sacral Neuromodulation Treat?
- Who Is a Candidate for Sacral Neuromodulation?
- Who Should Not Undergo Sacral Neuromodulation?
- Stages of Sacral Neuromodulation Testing
- Battery Life
- Possible Complications
- Precautions
- Security Systems
- Information on the Situation in Turkey and Institutional Payments
What Is Sacral Neuromodulation (Bladder Pacemaker)?
Sacral Neuromodulation (SNM) (Sacral Nerve Stimulation/Bladder Pacemaker) is a treatment method that stimulates the pelvic nerves and may help some people with bladder and bowel problems. When successful, it can be a life-changing therapy. As with all treatments, it is not suitable for everyone, and your doctor will determine whether it is right for you.
What Does Sacral Neuromodulation Treat?
- Overactive Bladder (OAB)
- Chronic Urinary Retention (CUR)
- Interstitial Cystitis/Bladder Pain Syndrome (IC/BPS)
- Fecal incontinence
Who Is a Candidate for Sacral Neuromodulation?
Sacral Neuromodulation (SNM): It is a treatment option when conservative approaches (such as lifestyle and dietary changes, medication, or biofeedback), medication, and other minimally invasive methods (such as Botox and hydrodistension) have proven ineffective.
It may be the only available treatment for certain patient groups. In patients with chronic urinary retention, the only known treatment options are clean intermittent self-catheterization (CIS) or indwelling suprapubic/transurethral catheters. CIS can sometimes be a painful and traumatic process, and SNM offers an effective alternative treatment.
Who Should Not Undergo Sacral Neuromodulation?
- People in poor general health
- Rectal prolapse
- Patients with cardiac conditions requiring a ventricular pacemaker
- Patients with bleeding disorders
- Patients who did not respond adequately at this stage
- Pregnancy
- Diabetes
- People with intellectual disabilities
- BPH
- Urethral stricture
- Malignancy
- People with bladder abnormalities
- Patients with complete transverse spinal cord injury due to spina bifida
Stages of Sacral Neuromodulation Testing
1- Implantation procedure (test phase):A permanent electrode is implanted in the lower back, close to the sacral nerve. The other end is connected to a temporary lead that is tunneled under the skin along your back and emerges through the skin. This electrode is connected to an external SNM the day after surgery. This external device contains a battery that is worn in a belt during the evaluation period. The procedure may involve three small incisions on your hips and lower back, which will be closed with stitches. The procedure typically takes less than 1 hour, and you may need to stay in the hospital for 1 day.
After the temporary lead is placed, you will go home and resume your daily activities, continuing to record your bladder habits in a new diary during this test.
After an evaluation period of 2–8 weeks on average, your doctor will explain and discuss the results with you. Various measurements will be used to assess whether you are benefiting from the treatment. Depending on your symptoms, these measurements may include recording the number of urinary incontinence episodes before and after the test, a quality-of-life assessment, and patient satisfaction. Generally, a reduction of more than 50% in your symptoms and findings indicates that you may be ready to proceed to the permanent implant phase.
If your evaluation is unsuccessful, the temporary lead will be removed at the clinic, and your doctor will consider repeating the test or discuss other options with you.
Stage 2 procedure (permanent implant stage):This involves the placement of a permanent battery connected to the previously implanted permanent electrode. During this procedure, which is typically performed under general anesthesia, the temporary lead emerging from the skin is removed. The permanent implant is usually placed just beneath the skin on the upper buttock. It measures approximately 3×4 cm. A thin lead is also placed in the lower back and connected to the device.
Battery Life
The typical battery life ranges from 5 to 10 years, depending on the battery size, the amplitude of the signal being used, and whether the battery is used continuously or intermittently.
Since sacral neuromodulation (SNM)—also known as sacral nerve stimulation (SNS)—was first introduced in the 1990s, it has proven to be an effective treatment for chronic dysfunction of the bladder, bowel, and pelvic floor. The sacral nerve controls the bladder, bowel, and pelvic floor, as well as the muscles involved in their function. The device is surgically implanted and stimulates the sacral nerve with mild electrical pulses. It enables the person to sense bladder fullness and the urge to urinate. It also helps the patient empty their bladder spontaneously and completely.
Possible Complications
- Infection
- Bleeding
- Pain at the injection site: The pain may radiate from the back to the buttocks and from the thigh to the toes. Temporary weakness in the leg has been reported in rare cases.
- Electrode migration (displacement): Patients should avoid high-intensity exercise, weightlifting, and strenuous activities such as stretching for at least 6 months to prevent the electrode from shifting out of place.
- Change in sensation: If there is a change in or loss of sensation, it may be necessary to adjust the settings on the SNM.
Patients receive a handheld programmer and a device card that they can carry with them at all times to provide information about the implant to any hospital, doctor, or dentist.
Precautions
- Patients MUST TURN OFF the SNM before engaging in activities that could become unsafe for themselves or others in the event of an unexpected jolt or shock (for example, while operating electrical appliances).
- MRI: If the patient needs to undergo an MRI scan for any reason, they should contact the department where the device was implanted.
- Ultrasound, lithotripsy (stone fragmentation), or radiation therapy may interfere with the SNM; therefore, the patient MUST TURN OFF the device during any examination.
- Diathermy (cautery): It is not safe to undergo monopolar diathermy after implantation. Inform everyone treating you that, due to the implanted SNM, you cannot undergo short-wave diathermy, microwave diathermy, or therapeutic ultrasound diathermy. Energy from diathermy can be transmitted through the implant and may cause serious tissue damage and injury, which could be life-threatening. It may also damage the implant’s components and lead to treatment failure. The only acceptable form of diathermy is bipolar diathermy.
Security Systems:
Theft prevention and security systems in stores and at the airport may be disabled due to SNM. These systems may also adversely affect SNM. To obtain permission to bypass any security device, the device ID card may be shown to an authorized person.
Devices: Occasionally, household appliances such as magnetic refrigerators and speakers may interfere with the SNM, in which case the SNM may need to be restarted. Keep in mind that even if the SNM is turned off, nearby powerful electrical appliances may affect its tip, potentially causing a sudden, brief shock or jolt.
Sports and Exercise:During the first three months after surgery, healthcare providers recommend that patients avoid heavy lifting and strenuous exercise, particularly movements that involve bending or twisting. However, horseback riding, skiing, and contact sports appear to be associated with a higher risk of lead or electrode fracture.
Pregnancy:The effectsof an SNMon pregnancy are largely unknown. Therefore, if you are planning to start a family or as soon as you find out you are pregnant, it is recommended that you have your SNM closed by the hospital. Having an SNM does not mean you will need an elective cesarean section. The decision regarding any obstetric intervention rests with the obstetrician.
Information on the Situation in Turkey and Institutional Payments
At university hospitals and Ministry of Health Training and Research Hospitals (those with training clinics); the cost will be covered by the Institution based on the decision of a council formed by the urology, neurology, and psychiatry clinics and in accordance with a report issued by a panel comprising physicians from these three (3) specialties.
General Indications
a) The patient must be under 55 (fifty-five) years of age.
b) The patient must be informed about the device, and a psychiatric consultation must confirm whether the patient possesses the cognitive and psychological capacity to use the device.
e) A neurology consultation must confirm the absence of any condition that could cause urinary dysfunction.
c) To proceed to permanent implantation, a reduction of at least 50% in clinical symptoms and signs must have been observed during the trial phase.
Medical indications
a) Chronic urinary retention
1) This procedure should be performed on patients in whom this condition has persisted for at least 1 (one) year.
2) Urodynamically:
1- Bladder capacity and compliance must be normal
2- There must be no intravesical obstruction
3- There must be detrusor contraction dysfunction, and myogenic causes must not be involved in the etiology of this condition
b) Refractory idiopathic overactive bladder
1) This treatment may be applied to patients who do not respond to antimuscarinic therapy or intradetrusor botulinum toxin injections and have been under observation for at least 2 (two) years.
c) Painful bladder syndrome (interstitial cystitis)
1) This procedure may be performed on patients who received this diagnosis at least 5 (five) years ago and have not responded to all oral and intravesical treatments.