Editing Functional: Neuromodulation (section)

== Electrical Stimulation For Emptying Disorders ==

=== Electrical Stimulation to the Nerve Roots ===
* '''The detrusor is usually innervated primarily by S3 and to a smaller extent by S2 or S4.'''
* '''Erectile stimulation is chiefly by S2, with a small contribution from S3 and none from S4.'''
* '''Rectal stimulation is by means of all three roots equally.'''
* The current Brindley stimulator uses the principle of post-stimulus voiding
** Relaxation time of the striated sphincter after a stimulus train is shorter than the relaxation time of the detrusor smooth muscle. When interrupted pulse trains are used, voiding is achieved between the pulse trains because of the sustained high intravesical pressure.
** Post-stimulus voiding has a few shortcomings because voiding occurs in spurts at above-normal bladder pressures; when the stimulus parameters are not properly adjusted the detrusor pressures can become too high, putting the upper tracts at risk; and movement of the lower limbs occurs during stimulation because the nerve roots also contain fibers innervating leg musculature, and this movement can be cumbersome for the patient.
* '''Electrical stimulation of the ventral sacral roots with some techniques to reduce detrusor hyperactivity and obviate striated sphincter dyssynergia has become an accepted treatment modality for LUTD in patients with SCI.'''

=== Transurethral Electrical Bladder Stimulation (TEBS) ===
* Facilitates emptying by establishing conscious control of the initiation and completion of a micturition reflex
* '''Only patients with an incomplete''' central or peripheral nerve '''lesions and with receptors still capable of reactivity and with a detrusor still capable of contractility will benefit from this technique.'''
** Patients with incomplete lesions have at least some nerve pathways between the bladder and the cerebral centers but are too weak to be efficient under normal circumstances. TEBS in this situation is hypothesized to activate specific mechanoreceptors in the bladder wall.
* Children with congenital neurogenic bladder dysfunction who have never experienced the urge to void require a biofeedback system to realize the nature and meaning of this new sensation induced by TEBS.
* Transurethral electrical stimulation has fallen out of favor for the most part.

=== Sacral Neuromodulation of Emptying Disorders ===
* '''Has been successful in patients with:'''
** '''Idiopathic nonobstructive retention'''
** '''Retention secondary to deafferentation of the bladder after hysterectomy'''
** '''Fowler syndrome'''

=== Percutaneous Tibial Nerve Stimulation for Emptying Disorders ===
* '''PTNS also has been studied in the setting of nonobstructive urinary retention'''