Improvement of bowel dysfunction with sacral neuromodulation for refractory urge urinary incontinence.

INTRODUCTION AND HYPOTHESIS: Sacral nerve stimulation (SNS) is approved for urologic indications in the USA and, recently, fecal incontinence. This study described concomitant bowel dysfunction and improvements in bowel and urinary symptoms and quality of life (QOL) in women with refractory urge urinary incontinence (UUI) receiving SNS. METHODS: Women (N = 36) with refractory UUI receiving SNS were prospectively enrolled. Surveys and exams were completed at baseline and follow-up, with symptom and QOL scores measured using validated scales (0-100, none-worst). RESULTS: A total 24 women were followed up at a median of 4.0 months post-implantation. Of these, 20 (83%) had bowel dysfunction, 13 (54%) used bowel medications at baseline, and 11 (45%) continued them after SNS. The mean/median urinary (54.8 to 32.6) and bowel (23.4 to 14.1) symptom scores improved significantly, as did urinary (64.2 to 14.3) but not bowel (2.4 to 0.0) QOL scores. CONCLUSIONS: Bowel dysfunction is common in women with refractory UUI. SNS improves urinary symptoms and QOL, but improvement in bowel symptoms does not translate into significant QOL changes.

Treatment of slow-transit constipation with sacral nerve modulation.

AIM: Constipation is common and a selection of the best treatment is difficult, especially for slow-transit constipation (STC). The aim of the study was to assess the effect of sacral nerve modulation (SNM) on STC. METHOD: A retrospective analysis of patients with STC, treated with SNM was undertaken. All were evaluated by cinedefecography, colon transit-time, Cleveland Clinic Constipation Score (CCS), SF-36 Quality of Life (QoL) and a bowel diary. Initially, all patients underwent a temporary implant for 4 weeks. The criteria of success were disappearance of necessity for laxatives or enema requirement, and improvement in QoL. RESULTS: Fifteen patients with STC were treated from March 2003 to May 2006. Nine (60%) underwent permanent implantation. After SNM, the mean improvement of Wexner Constipation Score (CCS) and QoL was 10 and 6.2 respectively. There were no complications. The mean follow-up period was 42 months. CONCLUSION: Sacral nerve modulation seems to be a useful option for STC.

Short-term effects of magnetic sacral dermatome stimulation for idiopathic slow transit constipation: sham-controlled, cross-over pilot study.

BACKGROUND AND AIM: An increase in recto-sigmoid colon activity through electrical stimulation of the sacral dermatomes has previously been reported. It has not been evaluated whether or not sacral dermatome stimulation has beneficial effects on constipation symptoms and anorectal function in constipated patients. Our aim was to evaluate short-term effects of magnetic stimulation of the sacral dermatomes on constipation symptoms and anorectal function in patients with idiopathic slow transit constipation. METHOD: Fourteen patients with idiopathic slow transit constipation were enrolled. Constipation symptoms, stool form and anorectal function were assessed before treatment, and at 3 and 6 weeks of treatment. Six-week treatment consisted of either a 3-week period of sham treatment or a 3-week period of magnetic stimulation of the S2-S3 dermatomes, which was performed in a randomized cross-over design. RESULTS: During the stimulation period, the frequency score of spontaneous bowel movements decreased in eight of the 14 patients (2.9 [2-3]vs 1.4 [0-2]), whose threshold volumes for urge to defecate and maximum tolerable volumes were significantly greater than those of the non-responders, and significantly decreased at the end of treatment. The degree of straining on defecation also significantly decreased in the responders. Responders had shorter right colonic transit time and longer left colonic transit time compared to the non-responders. Sham treatment did not affect constipation symptoms, stool form and rectal sensation. CONCLUSION: Sacral dermatome stimulation may offer potential for therapeutic benefit for a subset of patients with idiopathic slow transit constipation, particularly constipated patients with rectal hyposensation or hindgut dysfunction.

New and emerging treatment options for chronic constipation.

Chronic constipation remains a therapeutic challenge for today's physicians. Traditional approaches include use of fiber, osmotic laxatives, stimulant laxatives, prokinetic agents, biofeedback training, and surgery. These often are tried sequentially and episodically and have little evidence of long-term efficacy. Patients often report inadequate relief of symptoms. There is room for improvement, therefore, in the therapy of chronic constipation. Future advances largely will be based on insights into the enteric nervous system (ENS), the structure and function of which is being revealed in great detail. Manipulating the ENS pharmacologically offers the opportunity to reprogram this key control system to improve bowel function. For example, interneurons in the ENS display 5-HT4 receptors, activation of which enhances the peristaltic reflex. Prokinetic agents that stimulate those receptors, such as tegaserod and prucalopride, have demonstrated efficacy as investigational agents for the treatment of chronic constipation in large studies. Less well studied investigational drugs with presumed activity in the ENS include opiate antagonists and the nerve growth factor neurotrophin-3. Both of these types of agents have been shown to be effective in small groups of patients with constipation. Another approach under development is to stimulate colonic fluid secretion by opening chloride channels in the epithelium pharmacologically. Existing non-pharmacological treatments that can be improved include biofeedback training for pelvic floor dysfunction and surgery. Future developments include investigation of electrical stimulation of the colon and use of stem cells to repopulate degenerated populations of neurons, interstitial cells of Cajal, or smooth muscle cells.

Short-term effects of sacral nerve stimulation for idiopathic slow transit constipation.

This study assessed the short-term clinical and physiological effect of continuous sacral nerve stimulation in patients with slow transit constipation. Some patients with idiopathic slow transit constipation are unresponsive to conservative treatments, while colectomy has a variable and poorly predictable outcome. Sacral nerve stimulation is a less invasive and reversible procedure that enables direct neuromodulation of the pelvic floor and hindgut. It has been used successfully in the treatment of urologic disorders and fecal incontinence, and some of these patients with concurrent constipation have also noted improved stool frequency and rectal evacuation. Eight women (median age 47 years, median symptom duration 31 years, median stool frequency once per 6 days) were implanted with a temporary percutaneous stimulating S3 electrode for 3 weeks, attached to an external stimulator (Medtronic, Minneapolis,USA). A bowel symptom diary card, anorectal physiological studies, and a radiopaque marker transit study were completed before and during stimulation. Two patients had cessation or marked diminution of symptoms, including normalization of bowel frequency. Colonic transit did not return to normal in any patient. Rectal sensory threshold to distension was decreased during stimulation. Percutaneous temporary sacral nerve stimulation symptomatically improved a minority of patients with resistant idiopathic slow transit constipation. Sensory function was altered by stimulation. Further studies are required to identify patients who may benefit and to assess a range of stimulation parameters.

Electrical stimulation in spinal cord injury.

The use of electricity to stimulate nerves or muscles is nothing new. In the 18th century Galvani recognized that electricity could be converted into "nerve force". Numerous applications of electrical stimulation have been explored, most notably cardiac pacing, cochlear implants or transcutaneous electrical nerve stimulation (TENS) units for pain control. Spinal cord injury (SCI), with its "transecting lesion" that leaves intact nervous system below the injury completely disconnected from the centers that exert motor control provides the ideal opportunity for electrical stimulation use. Multiple applications are being investigated, including those for aerobic conditioning/cardiovascular exercise, cough and breathing assistance, improving bowel and bladder control, erection and ejaculation, hand grasp, spasticity management, neuro-muscular reeducation, standing and walking, etc. This review will focus on innovative and technologically advanced applications of electrical stimulation in the management of patients with spinal cord injury.

Malone antegrade continence enemas for autonomic dysreflexia secondary to neurogenic bowel.

A 42-year-old man with T-4 ASIA B thoracic paraplegia presented with chronic constipation, fecal incontinence, and bowel-related autonomic dysreflexia (AD) refractory to conservative bowel program. His usual toileting time lasted one to five hours. Antegrade continence enemas (ACE) were performed. The ACE technique, which requires creating a continent catheterizable appendicocecostomy, is described. Postoperatively, a daily enema was given through the stoma. The patient's toileting time was reduced to 20 minutes and his AD resolved. The role of the ACE is discussed in adult spinal cord injury (SCI).