The role of sacral neuromodulation in double incontinence

Five-year Results from the Prospective, Multicenter, Observational SOUNDS Study of Patients with Overactive Bladder Treated with the InterStim System for Sacral Neuromodulation

BACKGROUND

Although sacral neuromodulation (SNM) for overactive bladder (OAB) is an established therapy, there is a lack of high-quality, long-term data on real-life practice.

OBJECTIVE

To report on real-life therapeutic effectiveness, quality of life (QoL), disease severity, and safety as well as patient-reported symptom bother after approximately 5 yr of follow-up.

DESIGN, SETTING, AND PARTICIPANTS

A total of 291 OAB patients were enrolled at 25 French sites according to local standard of care. Sacral neuromOdUlation with InterStim therapy for intractable lower uriNary tract DySfunctions (SOUNDS) enrolled both de novo and replacement patients, and a total of 229 patients were permanently implanted.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Over the course of the study, patients were followed up six times with two follow-ups in the year after implantation and annually thereafter. Of the patients, 154 completed the final follow-up after a mean of 57.7 ± 3.9 mo.

RESULTS AND LIMITATIONS

The mean number of daily leaks in urinary urge incontinence (UI) patients was reduced from 4.4 ± 3.3 at baseline to 1.8 ± 2.6 after 5 yr in de novo and from 5.4 ± 4.9 to 2.2 ± 3.0 in replacement patients (both p < 0.001). Likewise, the number of voids in urinary frequency patients was reduced compared with baseline (de novo: reduced from 12.6 ± 4.0 [baseline] to 9.6 ± 4.3 [5 yr]; replacements: reduced from 11.5 ± 4.3 [baseline] to 9.2 ± 3.1 [5 yr]; both p < 0.05). Complete continence rates after 5 yr were 44% (25/57) in de novo and 33% (5/15) in replacement UI patients, and 68% (39/57) and 67% (10/15) of UI patients were categorized as therapy responders by showing a >50% improvement in leaks. Disease severity (Urinary Symptom Profile domain 2), Numeric Rating Scale-based symptom bother, and disease-specific QoL (Ditrovie) improved significantly in both groups at all visits (p < 0.001). Adverse events related to device or procedure occurred in 51% (140/274) of patients, with 66% (152/229) of the events being classified as minor (Clavien-Dindo grade I and II). Surgical revisions were reported in 39% (89/229), which include permanent explants in 15% (34/229) of patients.

CONCLUSIONS

SOUNDS demonstrates the sustained effectiveness and QoL improvements of SNM in OAB patients after 5 yr in real-world conditions while maintaining an acceptable safety profile consistent with literature.

PATIENT SUMMARY

This study confirmed that French overactive bladder patients had a sustained symptom and bother reduction, and improvements in quality of life up to 5 yr after sacral neuromodulation device implantation.

Sacral Neuromodulation with the InterStim System for Overactive Bladder: 3-Year Results from the French Prospective, Multicenter, Observational SOUNDS Study

BACKGROUND

SOUNDS strengthens the evidence basis of sacral neuromodulation (SNM) for overactive bladder (OAB) through real-world data.

OBJECTIVE

To analyze diary-based effectiveness, quality of life (QoL), disease severity, symptom bother, and safety data for SNM with the InterStim system up to 3 yr after implantation.

DESIGN, SETTING, AND PARTICIPANTS

Twenty-five representative French sites enrolled 291 patients with OAB followed according to the local standard of care. Overall, 229 patients received a de novo or replacement InterStim implant and had four follow-up visits, two within the first yr and annually thereafter. A total of 190 patients completed the fourth follow-up visit after a mean of 33.7 ± 3.7 mo.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The effectiveness outcomes measured were changes in daily voids and leaks and the therapy responder rates. Other outcomes included validated QoL data (Ditrovie and EuroQol 5-dimension 5-level questionnaires), disease severity (Urinary Symptom Profile [USP]), symptom bother rated using a numeric rating scale (NRS), and safety data. Follow-up data were compared to baseline results using the Wilcoxon signed-rank test.

RESULTS AND LIMITATIONS

Average daily voids and leaks were significantly reduced at all time points up to 3 yr after implantation (p < 0.05) except for voids at 21 mo in the group receiving a replacement device. The therapeutic response for urinary urge incontinence at the fourth follow-up was 72% for the de novo group and 86% for the replacement group. Disease-specific QoL (Ditrovie), OAB-specific symptom severity (USP domain 2), and NRS-rated disease bother were significantly improved at all visits (p < 0.001). Device- or procedure-related adverse events occurred in 49% of patients, with 68% of the events classified as minor (Clavien-Dindo grade I or II). Surgical revisions were performed in 33% of patients, including permanent removal in 13%, over a mean exposure time of 44.4 ± 15.3 mo.

CONCLUSIONS

This study confirms the safety and effectiveness of SNM for OAB and improvements in QoL and disease bother in real life.

PATIENT SUMMARY

Our study in French patients with overactive bladder showed that disease symptoms and bother were significantly reduced and quality of life was significantly improved over a study duration of approximately 3 yr after implantation of a device to stimulate nerves that control the bladder. This trial is registered at ClinicalTrials.gov as NCT02186041.

Case Report: Sacral Nerve Root Pelvic Neural Retraining, With Long-Term Sustainability After the Device Explantation

Introduction: Sacral-Nerve-Neuromodulation (SNM) is an effective treatment increasingly used in patients with urinary (UI) and fecal incontinence (FI). The way it acts in the body at its full potential have not yet been elucidated. The authors review the literature on SNM and the way it possibly works, relating it to a case with an unusually favorable outcome.

Case Presentation: A female presented with UI and FI. Operated for meningocele as a neonate. It the age of 5 bilateral Cohen ureter reimplantation performed for persistent urinary infections due to vesicourethral reflux. At the age of 13, she started complaining about UI associated with a hyper functional detrusor muscle. After a diary incontinence evaluation with a standardized questionnaire, SNM was applied at the age of 18 and was retained for 4 years. She was re-evaluated with a yearly follow-up.

Results: The patient retained the positive effect of SNM even after its removal and in addition showed signs of improvement. The patient developed the sensation of fillingness of the bladder and the rectum, which she never had before the SNM implantation, sensation which she retained 29 months after (last follow-up) device removal, allowing her to control her voids.

Discussion: The modern literature hypothesis that SNM contributes to the plasticity of the nerves through the stimulated area is supported by the present case, in which the SNM effect remained and led to improvements even after its removal. Device settings are presented as they may correlate with the result. This reinforces and expands the frontiers of SNM application and research.

Sacral neuromodulation for faecal incontinence following obstetric sphincter injury - outcome of percutaneous nerve evaluation

AIM

The purpose of this study was to assess the efficacy of percutaneous nerve evaluation (PNE) in women with faecal incontinence (FI) following obstetric anal sphincter injury and to relate the outcomes to baseline factors, with special emphasis on the extent of the sphincter defect.

METHOD

This was a prospective study at a tertiary colorectal referral unit at the University Hospital of North Norway conducted from 2012 to 2014. Sixty-three women underwent a 3-week PNE using a tined lead and the Verify^® external neurostimulator. The primary outcome was efficacy, defined as the percentage reduction in weekly FI episodes, and patients with a reduction of 50% or more were defined as responders. Baseline factors affecting the primary outcome were explored. Sphincter defects were classified with a validated three-dimensional endoanal ultrasound defect score.

RESULTS

Fifty-six (89%) of the 63 women were responders with a reduction in weekly FI episodes of 94.5%, from a median (interquartile range) of 4.8 (2.0-11.0) to 0.5 (0-2.0) (P < 0.001). Twenty-nine (52%) reported no weekly FI episodes, and urgency episodes disappeared in 18 (32%). In the multivariable linear regression model, efficacy was related to concomitant urinary incontinence (P = 0.04), body mass index (BMI) (P = 0.03) and pain during PNE (P = 0.046) but not to the extent of the sphincter defect (P = 0.1). Responders had a higher St Mark's score than nonresponders (P = 0.046).

CONCLUSIONS

The vast majority of women had successful PNE tests. Responders had higher baseline St Mark's scores than nonresponders. Efficacy was related to concomitant urinary incontinence, BMI and pain, not to the extent of the sphincter defect.

Sacral neuromodulation and female sexuality

INTRODUCTION AND HYPOTHESIS

An up-to-date review of the impact of a permanent sacral neuromodulation (SNM) implant (Medtronic, Minneapolis, Minnesota, USA) on female sexual function (FSF).

METHODS

Clinical studies published from January 2001 to February 2014 evaluating the impact and/or safety of permanent SNM on FSF were reviewed.

RESULTS

Nine studies were selected that investigated the impact on sexual response when the aim of the SNM was to resolve urinary symptoms mainly due to overactive bladder (seven studies) or faecal incontinence. Most women included were of menopausal age. Three studies included sexually inactive women. Post-SNM follow-up varied from 3 to 36 months. Meta-analysis of efficacy results was not possible primarily due to the heterogeneity of the sexual and pelvic dysfunctions. The most specific questionnaire assessing FSF was the Female Sexual Function Index (FSFI) used in six studies. During follow-up all women showed statistically significant improvement (p < 0.05) in at least one FSFI domain compared to baseline. In one study statistically significant improvement (p < 0.05) in the FSFI pain domain was exclusively detected in women with neurological disease. Two studies, however, using the questionnaire to screen for sexual dysfunction did not find any statistically significant differences after SNM. The most severe problems associated with FSF concern loss of libido and reduction in vaginal lubrication which were resolved in one woman following removal of the SNM implant.

CONCLUSIONS

Actual data are still insufficient to definitely assert the positive effect of SNM on FSF.

Percutaneous nerve evaluation based on electrode placement under control of autonomic innervation

BACKGROUND

Foramen needle electrode placement for percutaneous nerve evaluation (PNE) is currently carried out while observing the somatic motor response. This study investigated electrode placement while observing the autonomic as well as the somatic response.

METHODS

A consecutive series of ten patients (seven women) with a median age of 51.9 (range 30-75) years undergoing PNE for faecal incontinence (n = 6) and obstipation (n = 4) were investigated prospectively. Electrode placement was carried out under simultaneous electromyography (EMG) of the external anal sphincter (EAS) and internal anal sphincter (IAS) and cystomanometry.

RESULTS

PNE under control of somatic and autonomic nerve responses was carried out in all patients. In three out of ten patients, initial needle electrode placement showed single evoked EMG signals from the EAS. Final electrode placement resulted in adequate somatic motor and autonomic responses in all patients. Comparison of the increases in IAS EMG amplitude on the right and left stimulation sites for sacral nerves S3 and S4 demonstrated significant differences [S3 right: median 15.3 (interquartile range (IQR) 10.4; 20.1) µV vs. S3 left: median 11.6 (IQR 8.6; 16.0) µV, p = 0.034 and S4 right: median 24.1 (IQR 20.1; 37.2) µV vs. S4 left: median 12.0 (IQR 10.7; 13.7) µV, p = 0.012]. Stimulation-induced bladder activation was achieved in all seven patients with concomitant urinary dysfunction.

CONCLUSIONS

Control of not just the somatic motor response but also the autonomic nerve response during foramen needle electrode placement may objectify PNE.

Incontinence and Chronic Illness

Objetivo: explorar la producción y contenido de la información disponible a nivel mundial sobre el abordaje de la incontinencia urinaria (IU) e incontinencia fecal (IF) y su relación con la enfermedad crónica (EC). Materiales y métodos: a partir de una revisión de literatura en las bases de datos Cinahl, Ovid, Scielo, Medline y Psychoinfo, entre los años 2009 y 2012, bajo los descriptores de incontinencia urinaria e incontinencia fecal, en combinación con enfermedad crónica, con su traducción al inglés, se identificaron, analizaron y clasificaron los planteamientos sobre el tema de la incontinencia según relevancia para la comprensión de la misma en la situación de EC. Resultados: se presentan los estudios encontrados clasificados en cinco grandes grupos sobre IU e IF que incluyen los que ilustran la magnitud del problema por su frecuencia y tipología, los que establecen relación directa entre la incontinencia y la EC, los que describen otros factores asociados con la incontinencia y con la EC, los que abordan la forma de valorar la incontinencia y los que dan aportes respecto al manejo de la IU o IF en la EC. Conclusiones: la literatura tiene abundante producción científica en sus dos últimos años y a nivel mundial sobre la IU pero no en igual proporción sobre la IF. Existen modelos para la valoración, medición y comprensión del fenómeno así como para la intervención y atención puntual sobre la misma. No se reportan abordajes integrales al problema de la IU e IF en personas con EC.

Does sacral nerve stimulation improve global pelvic function in women?

AIM

Many women undergoing sacral neuromodulation for faecal incontinence have coexisting pelvic floor dysfunction. We used a global pelvic-floor assessment questionnaire to evaluate the effect of sacral neuromodulation on non-bowel related symptomatology.

METHOD

The electronic Personnel Assessment Questionnaire - Pelvic Floor (ePAQ-PF) is a validated Web-based electronic pelvic floor questionnaire. Women with faecal incontinence underwent assessment using the ePAQ. Pre- and poststimulator data were analysed over a 4.5-year period.

RESULTS

Forty-three women (mean age 56.5 years; median follow up 6.8 months) were included. All (100%) had urinary symptoms, 81.4% had vaginal symptoms and 85.7% described some sexual dysfunction. There was a significant improvement in faecal incontinence and in bowel-related quality of life (P < 0.005) as well as in irritable bowel syndrome (IBS)-related symptoms (P < 0.01) and in bowel-related sexual heath (P < 0.01). Symptoms of vaginal prolapse significantly improved (P = 0.05). There was also improvement in symptoms of overactive bladder (P = 0.005) and in urinary-related quality of life (P < 0.05). A global health improvement was reported in 58.1%, mainly in bowel evacuation (P < 0.01) and in vaginal pain and sensation (P < 0.05). In sexually active female patients, significant improvements in vaginal and bowel-related sexual health were seen (P < 0.005). Improvement in general sex life following stimulation was reported in 53.3%.

CONCLUSION

A Web-based electronic pelvic-floor assessment questionnaire has demonstrated global improvement in pelvic floor function in bowel, urinary, vaginal and sexual dimensions in women following sacral neuromodulation for faecal incontinence.

Neuromodulation for fecal and urinary incontinence: functional results in 57 consecutive patients from a single institution

BACKGROUND

Sacral nerve stimulation is a recognized treatment for fecal and urinary incontinence. Few articles have been published about patients presenting with both types of incontinence.

OBJECTIVE

The aim of this study was to report the functional results in patients operated on for simultaneous fecal and urinary incontinence by the use of sacral nerve stimulation.

DESIGN

This study is a retrospective analysis of prospectively collected data.

SETTINGS

The investigation was conducted in the academic departments of colorectal surgery and urology.

PATIENTS

Between January 2001 and March 2010, 57 consecutive patients (54 women) with a mean age of 58 years (range, 16-76) were included.

INTERVENTIONS

Two-stage sacral nerve modulation (test and implant) was performed.

MAIN OUTCOME MEASURES

Functional study before testing, at 6 months, and at the end of follow-up after implantation included the use of the Cleveland Clinic incontinence score, Urinary Symptoms Profile, Fecal Incontinence Quality of Life score, and the Ditrovie score. Patient satisfaction with the technique was evaluated at a median follow-up of 62.8 months.

RESULTS

: Fecal incontinence improved from 14.1/20 to 7.2/20 at 6 months and 6.9/20 at the end of follow-up. Urinary incontinence, mainly urge incontinence (47% of patients), and urgency frequency (34% of patients) improved at 6 months and end of follow-up, but not retention and dysuria. Specific quality of life was improved for fecal and urinary incontinence at 6 months and end of follow-up. At the end of follow-up, 73% patients were highly satisfied with the technique, but 9% felt their condition had deteriorated. The reoperation rate was 29%, of which 12% were indicated because of a complication.

LIMITATIONS

This study was limited by its retrospective nature and the multiple causes of incontinence.

CONCLUSION

Fecal and urinary incontinence, studied by symptoms scores and specific quality-of-life scores, are improved in patients receiving sacral nerve stimulation for double incontinence.

Do the urinary bladder and large bowel interact, in sickness or in health? ICI-RS 2011

Normal functioning of the urinary bladder and the distal gut is an essential part of daily physiological activity coordinated by the peripheral and central nervous systems. Pathological changes in one of these organs may induce the development of cross-organ sensitization in the pelvis and underlie clinical co-morbidity of genitourinary and GI dysfunctions. Experimental human and animal data suggest that the bladder and distal colon interact under both normal and pathological conditions, however, the directions of these interactions can change dramatically depending on the nature and duration of the applied stimuli. This review article aimed to summarize the clinical data on colon-bladder cross-reflexes in healthy individuals, as well as in patients with co-morbid disorders. It also discusses currently used animal models, experimental approaches, and suggested mechanisms of colon-bladder cross-talk. Additionally, it provides an overview of the potential pharmacological targets to develop treatment options for patients with co-morbid disorders. Presented work resulted from the discussion of colon/bladder interactions during "Think Tank 9" presentations at the International Consultation on Incontinence Research Society meeting held in Bristol, UK, 2011.