Sacral Neuromodulation Effective for BPS/IC

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Sacral Neuromodulation Effective for Pain of Interstitial Cystitis

Jill Stein

April 26, 2010 (Barcelona, Spain) — Chronic sacral neuromodulation (SNM) provides effective long-term control of refractory painful bladder syndrome/interstitial cystitis (PBS/IC), according to results released here at the European Association of Urology 25th Annual Congress.

The study, from a Canadian team, found that symptoms improved in about 75% of patients with refractory PBS/IC who had an SNM device implanted. Thus far, the benefits have been maintained for a mean of 5 years.

"Painful bladder syndrome/interstitial cystitis is a disabling chronic condition that does not improve with standard behavioral and medical treatment in approximately 30% to 40% of patients," Jerzy Gajewski, MD, president of the Canadian Urological Association and professor of urology and pharmacology at Dalhousie University in Halifax, Nova Scotia, told Medscape Urology.

"Based on our results, we believe that the treatment should be considered after the patient has failed behavioral, pharmacologic, or intravesical therapy, and before considering an invasive surgical intervention."

Roughly 0.5% of women and men in Canada have PBS/ISC, Dr. Gajewski noted. First-line therapy typically involves behavioral treatment, such as biofeedback, and a PBS/IC diet and medical treatment, such as the use of pentosan polysulfate (Elmiron) or intravesical dimethyl sulfoxide or heparin.

Chronic SNM, which is a minimally invasive procedure, is approved by the US Food and Drug Administration and Health Canada for managing the frequency-urgency syndrome, urge incontinence, and idiopathic urinary retention.

Dr. Gajewski reported data for all patients who underwent peripheral nerve evaluation followed by chronic SNM at his institution for the treatment of PBS/IC over a recent 14-year period.

All patients in the series satisfied the International Continence Society criteria for PBS/IC, had cystoscopic evidence of glomerulation or ulcer, as recommended by the European Society for the Study of IC/PBS, and had received conventional treatment.

Seventy patients were male, and 8 were female. The mean age was 42.37 years, and the mean symptom duration before the implant was 49.71 months.

"Our patient population is typical of patients presenting with IC/PBS," Dr. Gajewski said.

The primary end point of the study was the overall improvement in the global response assessment (GRA) scale.

Of 78 patients who underwent the peripheral nerve evaluation test, 46 (59%) showed at least 50% improvement in their GRA scores and voiding diaries after 5 days of stimulation.

These patients subsequently underwent permanent implantation of the sacral neuromodulator.

At a mean follow-up of 61.5 months, chronic stimulation aimed at controlling symptoms was successful in 33 patients (72%). The median improvement in their symptoms on the GRA scale was 80%.

The revision rate was high (50% of procedures) and was usually due to a worsening of symptoms.

Overall, the sacral neuromodulator had to be removed in 13 patients (28%). The average improvement on the GRA scale in the explantation group was 38%.

Further analysis revealed that urgency was a good predictor of long-term success (P = .027).

Dr. Gajewski said that the treatment works by improving not only the voiding dysfunction but also the pelvic pain by modulating afferent sensory processing and pelvic floor and detrusor efferent pathways.

"This is a difficult-to-manage group of patients," Gerald L. Andriole, MD, chief of the Division of Urologic Surgery at Washington University School of Medicine and Barnes-Jewish Hospital in St. Louis, Missouri, said in an interview with Medscape Urology. "I cannot really put it in perspective because I am not sure what they considered 'conservative management.' However, these patients are often desperate so the findings are encouraging."

He did note that because "half of the implants needed revision and 25% or so didn't work with this approach, there is still a lot of follow-up [and] ongoing care and reevaluation that is needed. It doesn't look like [this is] the single, final treatment for many of these patients."

Dr. Gajewski and Dr. Andriole have disclosed no relevant financial relationships.

European Association of Urology (EAU) 25th Annual Congress: Abstract 646. Presented on April 18, 2010.

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"Based on our results, we believe that the treatment should be considered after the patient has failed behavioral, pharmacologic, or intravesical therapy, and before considering an invasive surgical intervention."

They don't mention physiotherapy, neuromuscular or psychological.

Question: is a "sacral neuromodulator" just a medicalized way of achieving the same thing that trigger point massage and conscious relaxation can achieve? Using a hammer to kill a gnat?

[kevin]

Question: is a "sacral neuromodulator" just a medicalized way of achieving the same thing that trigger point massage and conscious relaxation can achieve?

Probably different, although no one knows exactly why sacral neuromodulation works. The most common hypothesis is that it interferes with excitatory nerve signals from the bladder to the brain.

It's counterintuitive because normally, stimulating the sensory nerves would increase bladder sensation. However, with the right electrode placement and stimulation frequency (i.e. hertz), you can achieve the opposite effect.

(Interstim had no effect for me, BTW.)

[webslave]

Sacral nerve modulation in the treatment of chronic pelvic pain

[kenn101]

I found that Gabapentin helped me somewhat but the Interstim didn't do a thing for me. When I did the interstim trial they looked at a muscle around my anus to make sure the sacral neuromodulation was working properly. I found it to be like a TENS therapy devise with the similar adjustments of how strong and how long it fired but with two 3 setting controls which was for the 3 heads of the needle that fires on the s3 nerve as it goes along the coccyx bone. The only control I was to use was the strength but that was 6 years ago.

[ppp]

I searched the forum, did not see a discussion on this.

See this:
https://pubmed.ncbi.nlm.nih.gov/30874835

Any thoughts?

[webslave]

Sacral neuromodulation has not been studied in CPPS. More questions than answers
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3753408/