FES for Bladder: Direct or Indirect Means?

Abstract

Efforts to restore function to the neurologically disabled lower urinary tract by direct electrical stimulation of the bladder wall have met with only very limited success. This has been due to pain and cocontraction of bladder outlet mechanisms caused by presumed spread of the large currents required to effectively directly stimulate the detrusor muscle. Stimulation at the four anatomical sites of the sacral neural outflow on the other hand has been more successful. Conus medullaris stimulation has resulted in "good results" in just over half of the 28 patients so treated. Acceptance of this technique has been limited by the poor selectivity of the intramedullary electrodes in stimulating only the target motor neurons and the resultant clinical problems with the consequent stimulus current spread. Sacral anterior root stimulation has been used in at least 88 patients with generally good results. Cocontraction of the detrusor and external urethral sphincter are circumvented by the use of an intermittent pattern of stimulation. The primary disadvantage of this technique is the obligatory placement of the electrodes within the cerebrospinal fluid compartment. Clinical experience with stimulation of the extradural sacral mixed nerves is limited. Experimental studies indicate that success with this technique requires dorsal rhizotomy and pudendal neurotomy. Preliminary clinical experience suggests that these surgical manipulations may not be necessary for a successful outcome. The literature on clinical application of pelvic nerve stimulation is too limited for detailed comment on this technique. A definitive technique for restoration of bladder function by electrical stimulation remains to be developed.

Sacral Anterior Root Stimulation for Bladder Control: Clinical Results

“…The extra-dural approach (Schmidt, 1986;Talalla, 1986;Talalla et al, 1986Talalla et al, , 1987Tanagho & Schmidt, 1988;Tanagho et al, 1989) does not have this disadvantage, but carries a higher risk of anterior root damage and failure to deafferentiate completely (Tanagho & Schmidt, 1988;Tanagho et al, 1989;Sauerwein et al, 1990). In our opinion it is virtually impossible to separate the mixed sacral nerves safely and precisely into anterior and posterior components extra-durally.…”

“…In the past, efforts to restore bladder control in these patients using electrical stimulation have been unsuccessful due to the fact that the nerve roots that supply the sphincter muscles and the bladder muscles contract simultaneously upon electrical stimulation, thereby counteracting each other (Brindley, 1986;McGuire, 1986;Schmidt, 1986;Talalla, 1986;Talalla et al, 1987). Nowadays, through the development of a device designed by Brindley (Brindley et al, 1982Brindley 1986Brindley , 1991, electrical stimulation gives good results in the management of neurogenic dysfunction of the bladder.…”

Sacral anterior root stimulation for bladder control in patients with a complete lesion of the spinal cord

“…Electrical stimulation of the sacral roots to restore bladder function in patients with a neurogenic bladder has been largely unsuccessful in the past, because of the fact that the sphincter muscles are supplied by the same nerve roots as the bladder and both contract with the electrical stimulus [8,13,[18][19][20].…”

Control of urinary bladder function with devices: successes and failures

“…Many review articles have been published that focus on devices for bladder control (Schmidt, 1983;Talalla et al, 1987;Lee, 1997;Rijkhoff et al, 1997b;Grill et al, 2001;Groen and Bosch, 2001;Jamil, 2001;Jezernik et al, 2002;Van Kerrebroeck, 2002;Middleton and Keast, 2004;Rijkhoff, 2004b;van Balken et al, 2004), so no attempt will be made to provide detailed descriptions of each of these methods here. Rather, we will summarize the methods that have been devised over the years for device-based management of the neurogenic bladder secondary to spinal cord injury and summarize current research on those devices and methods that are likely to affect the field in the future.…”