Electrical neuromodulation in the management of lower urinary tract dysfunction: evidence, experience and future prospects

Abstract

Lower urinary tract dysfunction (LUTD) is common and causes a spectrum of morbidity and decreased quality of life (QoL) for patients. LUTD can range from urinary retention to urge incontinence, and includes a variety of syndromes, with the most common and widely recognized being overactive bladder (OAB). The classic treatments of LUTD and OAB comprise different strategies including behavioral therapies, medications and minimally invasive or invasive surgical procedures. Generally, once patients have tried behavioral modifications and oral medical therapy, and have not experienced adequate relief of their symptoms, the next step is to consider minimally invasive therapies. In the last two decades since FDA approval, sacral nerve stimulation (SNS) has become an accepted intervention, with increasing use and evidence of effectiveness for LUTD, specifically OAB and non-obstructive urinary retention. SNS has shown both objective and subjective improvement in voiding symptoms in several randomized controlled trials (RCTs) when compared to sham or standard medical therapy. The main limitations for more extensive use include relatively high cost, implantation of a device and possibly reoperation secondary to adverse events (AE). Percutaneous tibial nerve stimulation (PTNS) is a less invasive, less direct and less expensive method for neuromodulation, which has also shown effectiveness in several randomized and non-randomized trials, including comparable improvement rates to anticholinergics in OAB management. However, the efficacy of PTNS is only maintained for a short period after the stimulation is delivered. This technique has a much lower rate of AE compared to SNS, but with the inconvenience of weekly visits for stimulation, although implantable devices are on the horizon. In this article we review the mechanism of action, indications, effectiveness and complications related to SNS and PTNS therapy for LUTD.

Functional segregation within the pelvic nerve of male rats: a meso‐ and microscopic analysis

“…Whereas the vagus regulates abdominal and thoracic organs, the pelvic organs are instead primarily innervated by more caudal neural circuits that have also become a focus of neuromodulation (Gaunt and Prochazka, 2006;Liberman et al 2017;Abello and Das, 2018;Kessler et al 2019;Moore et al 2019). Specifically, the 'sacral' component of the parasympathetic system, working together with sacral afferent pathways, is critical for micturition, defecation and sexual function; furthermore, sacral afferents also function in inflammatory and pain conditions originating in the pelvic organs (Gonzalez et al 2014;de Groat and Yoshimura, 2015;Grundy et al 2019).…”

Multimodal treatment of myophasal chronic pelvic pain in women: institutional experience

“…The importance of identifying and treating the hypertonic component of the pelvic floor allows better control and prevents the perpetuation of the disease and improving the quality of life of patients. 18,19 The vaginal electro stimulation at high and medium frequencies has an analgesic effect which is achieved by producing heat over the application area, decreasing local inflammation mediators, which, as we know, play an important role in the pathophysiology of the myofascial syndrome. He attributes that by direct stimulation on the nerve terminals it causes desensitization, thereby reducing the painful stimulus.…”

“…He attributes that by direct stimulation on the nerve terminals it causes desensitization, thereby reducing the painful stimulus. 18 There is little medical evidence about the use of analgesic electro-stimulation for chronic pelvic pain, and much less in the application of myofascial pain of the pelvic floor with endocavitary catheter. Most of the literature focuses on the use of this treatment in urinary incontinence.…”

Suppression of Urinary Voiding “on Demand” by High-Frequency Stimulation of the S1 Sacral Nerve Root in Anesthetized Rats

“…Sacral neuromodulation is the most commonly used, clinically effective intervention, for treating a number of urinary and bowel dysfunctions that are refractory to conservative management. Several recent evaluations conclude that as experience grows, considerable levels of long‐term therapeutic success (>50% improvement in main symptoms/leakage episodes) and improved quality of life can be expected in patients with urinary urge incontinence and urgency frequency. Nonetheless, adverse effects such as pain and the requirement for reintervention still remain problematic .…”