Functional: Neuromodulation: Difference between revisions

(2 intermediate revisions by the same user not shown)

Line 94:

* Insert figure

* '''Procedure'''

** See CW11 Figure 81-4 for image of tined lead being introduced into sacral space

** '''The location of the S3 foramen is approximated by measuring 9 cm cephalad to the drop-off of the sacrum and 1-2 cm lateral to the midline on either side'''.

** '''The nerve is tested for the appropriate S3 motor response:'''

** '''<span style="color:#ff0000">The nerve is tested for the appropriate S3 motor response:'''

*** '''Test stimulation is repeated on each electrode, and the responses are observed.'''

*** '''Sacral nerve responses'''

Line 120:

Line 119:

|}

*'''An S3 response should be noted on ≥2 of the electrodes'''

*'''<span style="color:#ff0000">An S3 response should be noted on ≥2 of the electrodes'''

** '''A sensory response is not needed to confirm proper placement if the correct S3 motor response is observed, although this is debatable.'''

*** '''Although controversial, proper localization of the device may be improved if one can localize the stimulation at the time of lead positioning to sensation of the vagina-rectum juncture in females and perineoscrotal area in males'''

Line 274:

Line 273:

== Electrical Stimulation For Emptying Disorders ==

* '''Electrical Stimulation to the Nerve Roots~~'''~~

=== Electrical Stimulation to the Nerve Roots ===

** '''The detrusor is usually innervated primarily by S3 and to a smaller extent by S2 or S4.'''

* '''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.'''

* '''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.'''

* '''Rectal stimulation is by means of all three roots equally.'''

** The current Brindley stimulator uses the principle of post-stimulus voiding

* 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.

** 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.

** 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.'''

* '''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

=== Transurethral Electrical Bladder Stimulation (TEBS) ===

** '''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.'''

* Facilitates emptying by establishing conscious control of the initiation and completion of a micturition reflex

*** 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.

* '''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.'''

** 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.

** 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.

** Transurethral electrical stimulation has fallen out of favor for the most part.

* 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.

* '''Sacral Neuromodulation of Emptying Disorders~~'''~~

* Transurethral electrical stimulation has fallen out of favor for the most part.

** '''Has been successful in patients with:'''

*** '''Idiopathic nonobstructive retention'''

=== Sacral Neuromodulation of Emptying Disorders ===

*** '''Retention secondary to deafferentation of the bladder after hysterectomy'''

* '''Has been successful in patients with:'''

*** '''Fowler syndrome'''

** '''Idiopathic nonobstructive retention'''

* '''Percutaneous Tibial Nerve Stimulation for Emptying Disorders~~'''~~

** '''Retention secondary to deafferentation of the bladder after hysterectomy'''

** '''PTNS also has been studied in the setting of nonobstructive urinary retention'''

** '''Fowler syndrome'''

=== Percutaneous Tibial Nerve Stimulation for Emptying Disorders ===

* '''PTNS also has been studied in the setting of nonobstructive urinary retention'''

== Questions ==

Line 302:

Line 304:

== Answers ==

#What the putative mechanism of action of neuromodulation?

# What are the contraindications to neuromodulation?

== References ==

* Wein AJ, Kavoussi LR, Partin AW, Peters CA (eds): CAMPBELL-WALSH UROLOGY, ed 11. Philadelphia, Elsevier, 2015, chap 81

@@ Line 94: / Line 94: @@
 * Insert figure
 * '''Procedure'''
-** See CW11 Figure 81-4 for image of tined lead being introduced into sacral space
 ** '''The location of the S3 foramen is approximated by measuring 9 cm cephalad to the drop-off of the sacrum and 1-2 cm lateral to the midline on either side'''.
-** '''The nerve is tested for the appropriate S3 motor response:'''
+** '''<span style="color:#ff0000">The nerve is tested for the appropriate S3 motor response:'''
 *** '''Test stimulation is repeated on each electrode, and the responses are observed.'''
 *** '''Sacral nerve responses'''
@@ Line 120: / Line 119: @@
 |}
-*'''An S3 response should be noted on ≥2 of the electrodes'''
+*'''<span style="color:#ff0000">An S3 response should be noted on ≥2 of the electrodes'''
 ** '''A sensory response is not needed to confirm proper placement if the correct S3 motor response is observed, although this is debatable.'''
 *** '''Although controversial, proper localization of the device may be improved if one can localize the stimulation at the time of lead positioning to sensation of the vagina-rectum juncture in females and perineoscrotal area in males'''
@@ Line 274: / Line 273: @@
 == Electrical Stimulation For Emptying Disorders ==
-* '''Electrical Stimulation to the Nerve Roots'''
+=== Electrical Stimulation to the Nerve Roots ===
-** '''The detrusor is usually innervated primarily by S3 and to a smaller extent by S2 or S4.'''
+* '''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.'''
+* '''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.'''
+* '''Rectal stimulation is by means of all three roots equally.'''
-** The current Brindley stimulator uses the principle of post-stimulus voiding
+* 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.
+** 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.
+** 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.'''
+* '''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
+=== Transurethral Electrical Bladder Stimulation (TEBS) ===
-** '''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.'''
+* Facilitates emptying by establishing conscious control of the initiation and completion of a micturition reflex
-*** 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.
+* '''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.'''
-** 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.
+** 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.
-** Transurethral electrical stimulation has fallen out of favor for the most part.
+* 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.
-* '''Sacral Neuromodulation of Emptying Disorders'''
+* Transurethral electrical stimulation has fallen out of favor for the most part.
-** '''Has been successful in patients with:'''
-*** '''Idiopathic nonobstructive retention'''
+=== Sacral Neuromodulation of Emptying Disorders ===
-*** '''Retention secondary to deafferentation of the bladder after hysterectomy'''
+* '''Has been successful in patients with:'''
-*** '''Fowler syndrome'''
+** '''Idiopathic nonobstructive retention'''
-* '''Percutaneous Tibial Nerve Stimulation for Emptying Disorders'''
+** '''Retention secondary to deafferentation of the bladder after hysterectomy'''
-** '''PTNS also has been studied in the setting of nonobstructive urinary retention'''
+** '''Fowler syndrome'''
+=== Percutaneous Tibial Nerve Stimulation for Emptying Disorders ===
+* '''PTNS also has been studied in the setting of nonobstructive urinary retention'''
 == Questions ==
@@ Line 302: / Line 304: @@
 == Answers ==
+#What the putative mechanism of action of neuromodulation?
+# What are the contraindications to neuromodulation?
 == References ==
 * Wein AJ, Kavoussi LR, Partin AW, Peters CA (eds): CAMPBELL-WALSH UROLOGY, ed 11. Philadelphia, Elsevier, 2015, chap 81