Aims

The objective of the study was to compare sacral nerve stimulation (SNS) to pudendal nerve stimulation (PNS) for voiding dysfunction.



Methods

Thirty subjects with voiding dysfunction had a tined lead placed at S3 and a second electrode implanted at the pudendal nerve via a posterior approach. In a blinded, randomized fashion, each lead was tested for 7 days. Voiding diaries and questionnaires were completed and outcomes monitored.



Results

The time to place a sacral lead was 25.85 min, pudendal lead 23.71 min (P = 0.57). Twenty-four of 30 (80%) subjects responded and had a permanent implant placed. PNS was chosen as a superior lead in 79.2%, SNS was superior in 20.8%. The order in which the lead was simulated had no impact on the final lead implanted and no carry over effect was seen. Overall reduction in symptoms was 63% for PNS and 46% for SNS (P = 0.02). On a 7-point scale from markedly worse to markedly better, the pudendal lead was superior to sacral for pelvic pain (P = 0.024), urgency (P = 0.005), frequency (P = 0.007), and bowel function (P = 0.049). Complications were minimal.



Conclusions

This is the first blinded study of sacral versus pudendal stimulation for voiding dysfunction. Successful implantation of a pudendal lead was achieved in all subjects. The majority of subjects chose PNS to be superior to SNS. More patients and longer term data is needed to confirm these promising results. © 2005 Wiley-Liss, Inc.

Sacral versus pudendal nerve stimulation for voiding dysfunction: a prospective, single-blinded, randomized, crossover trial.

Potentially the greatest role for pelvic floor muscle re-education is to prevent insufficiency of this muscle group. Current therapy of pelvic floor dysfunction involves physiotherapy to recover some muscular function, or surgery to compensate and in some cases overcorrect anatomic defects. None of these treatments is able to restore the pelvic floor to its original structure and function. Training these muscle groups to increase muscular tone and control might enable the pelvic floor to withstand the pressures of abdominal strain or gravity. Prevention of pelvic floor insufficiency should therefore be a major goal of pelvic floor re-education.

/pdf/pelvic-floor-re-education-3k0qrluzz8.pdf

Pelvic Floor Re-education

A urodynamic study of surface neuromodulation versus sham in detrusor instability and sensory urgency

Objective

 To assess the long-term (3–9 years) results of augmentation ileocystoplasty for non-neurogenic female urge incontinence in terms of continence, the need for intermittent self-catheterization and the need for additional or auxiliary treatment, to define the long-term complications and to assess the patients’ satisfaction with the outcome.



Patients and methods

 The study comprised 51 women who underwent augmentation ileocystoplasty for non-neurogenic urge incontinence between November 1987 and December 1993; 27 patients had associated interstitial cystitis. All patients had exhausted conservative methods, with an unsatisfactory outcome. All patients were interviewed about the results of the procedure, and their charts reviewed and updated with relevant information.



Results

 Within a mean (range) follow-up of 75.4 (36–109) months, 27 patients (53%) were completely continent, 13 (25%) had occasional leaks and nine (18%) continued to have disabling urge incontinence frequently requiring pads. Regular self-catheterization was needed by 20 (39%) patients while the rest emptied adequately with no or minimal residual volumes. Additional pharmacotherapy had to be used by 12 (24%) patients. Three patients later developed stress urinary incontinence and were managed with fascial sling procedures. The patch was revised in two patients and excised from four others because they had high residual volumes and uncontrollable infections. Two patients had an ileal conduit diversion for persistent incontinence. The most common complication was recurrent urinary tract infections, seen in 22 patients using intermittent self-catheterization. Mucus retention occurred regularly in 10 patients, six had chronic diarrhoea, four had latent bowel obstruction, one developed a bladder stone, one an incisional hernia and one developed patch necrosis and perforation. Twenty-seven patients (53%) were happy with the outcome of the procedure while 20 (39%) were not; four patients were unsure whether a change had occurred.



Conclusion

 Augmentation ileocystoplasty is a valuable alternative for women with intractable urge incontinence. However, these patients and their physicians should be aware of its limitations, specifically the possibility that incontinence may persist and the high probability of the need for self-catheterization, with potential subsequent urinary tract infection.

Long-term results and complications of augmentation ileocystoplasty for idiopathic urge incontinence in women.

Objective : To examine what is attainable when treating urinary incontinence in women in general practice. Design : Observational study with 12 months9 follow up. Interview and clinical examination before, during, and after treatment of women seeking help for urinary incontinence in general practice. Setting : General practice in the rural district of Rissa, Norway. Subjects : 105 women aged 20 or more with urinary incontinence. Interventions : Treatment with pelvic floor exercises, electrostimulation, oestrogen, anticholinergic drugs, bladder training, and protective pads. Main outcome measures : Subjective and objective measures of urinary incontinence; number of patients referred to a specialist. Results : After 12 months9 follow up 70% (69/99) of the women were cured or much better; the mean score on a 100 mm visual analogue scale decreased from 37 to 20 mm; and the proportion of women who were greatly bothered by their incontinence decreased by 62%. 20% (20/98) of women became continent, and the percentage of women with severe incontinence decreased from 64% (63/99) to 28% (27/98). Mean leakage per 24 hours measured by a pad test decreased from 28 g at the start of treatment to 13 g after 12 months. The number of light weight pads or sanitary towels decreased from 1.6 to 0.6 a day. In all, 17/105 (16%) patients were referred to a specialist. Conclusions : Urinary incontinence in women can be effectively managed in general practice with fairly simple treatment. Most women will be satisfied with the results. Key messages General practitioners can treat urinary inconti- nence fairly simply Treatment options in this study were pelvic floor exercises, electrostimulation, oestrogen, anti- cholinergic drugs, bladder training, and protective pads After 12 months9 follow up most of the women were cured or much better

/pdf/treatment-of-urinary-incontinence-in-women-in-general-3vxgc7aa1c.pdf

Treatment of urinary incontinence in women in general practice: observational study.

A new device for in-clinic acute maximal electric stimulation of the pelvic floor has been developed to treat motor and sensory dysfunction of the lower urinary tract.



Forty-eight women suffering from idiopathic detrusor instability and urge urinary incontinence received an average of seven treatments, each lasting for 20 minutes. A mean current intensity of 86 mA using monophasic square pulses with a frequency of 5–10 Hz and a pulse width of 1 msec was delivered simultaneously through a vaginal and an anal plug electrode.



Initially, clinical and urodynamic cures were obtained in about 50% of the patients. In addition, a significant improvement was observed in approximately 33%. At 1-year follow-up, a persisting positive therapeutic effect was found in 77% of the study group, and no serious side effects were registered.



The stimulation device used, the “Medicon MS-103,” which is commercially available, was easy to handle, safe for the patients, and technically reliable. Disposable plugs satisfied hygienic requirements. Low-frequency, repetitive, short-term maximal electrostimulation of the pelvic floor is a simple, effective, low-cost therapeutic method in female idiopathic motor urge incontinence.

Maximal electrostimulation of the pelvic floor in female idiopathic detrusor instability and urge incontinence

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Maximal electrostimulation of the pelvic floor in female idiopathic detrusor instability and urge incontinence