DOCSLIB.ORG

Studies of the Mechanisms of Sacral Nerve Stimulation for Faecal

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Studies of the Mechanisms of Sacral Nerve Stimulation for Faecal Studies of the Mechanisms of Sacral Nerve Stimulation for Faecal Incontinence: Investigations of Anorectal and Pelvic Floor Physiology and Function Mostafa Rabieh El-Said Abdel-Halim MBBCh, MSc, MRCS Division of Surgery & Interventional Science, University College London 2012 A thesis submitted in fulfillment of the requirements for the award of the degree of Doctor of Medicine (Research) 1 Dedication To Ayman – you are always in my thoughts To Mr Shandall – for his sincere advice 2 Declaration I, Mostafa R. E. Abdel-Halim confirm that the work presented in this thesis is my own. All the work was undertaken at the University College London Hospital. 3 Abstract Studies of Sacral Nerve Stimulation (SNS) have demonstrated significant symptom improvement in Faecal Incontinence (FI); however, mechanisms of action remain poorly understood. Various authors have examined anorectal physiological parameters with SNS; and apart from an observed increase in squeeze pressures, findings were mostly inconsistent. It is currently believed that effects are mediated through neuromodulation. Identification of the involved neuronal pathways and the associated changes at the level of the target organ can further inform the process of patient selection for this costly treatment. The aim of this thesis was to examine potential SNS mechanisms by studying its effects on the sphincteric and suprasphincteric properties utilising physiological and structural tests. A total of 30 patients (29 female, median age 49 years) with intractable FI undergoing temporary SNS were recruited into four different studies designed to examine associated physiological and structural changes. The study of rectal properties revealed no change in rectal compliance following stimulation. However, rectal pressures associated with urge perception and maximally tolerated distension were significantly increased; predominantly in clinical responders. 4 Anal squeeze pressures were significantly increased after stimulation in both responders and nonresponders. However, an increase in resting pressure was only noted in responders. Furthermore, Recto-Anal Inhibitory Reflex (RAIR) recovery time was significantly shorter after stimulation. An acute ON/OFF alteration of stimulation did not result in an acute change in anal pressures or RAIR parameters. Magnetic Resonance Proctography revealed a trend of reduced duration of rectal emptying after stimulation. Furthermore; it has suggested that more efficient contrast evacuation occurs after SNS. Mechanisms of SNS are most probably complex and multi-factorial. The observed changes in rectal sensory thresholds, RAIR recovery time and rectal evacuation in this study suggest that SNS influences the anorectal autonomic function and that it has an afferent-mediated mechanism. 5 Acknowledgements First and foremost, I would like to thank Dr Anton Emmanuel, my supervisor and mentor. No words can adequately express my gratitude to him. His advice, expertise, supervision and limitless guidance were what made this work possible. I am deeply indebted to him. I would also like to thank Mr Richard Cohen and Dr Stuart Taylor for their guidance and support. Many thanks are also due to Dr Amanda Raeburn and all the staff at the GI Physiology Unit. Amanda's never-ending willingness to help and support makes her so special. She will be forever remembered. Last, but not least, I would like to thank my dear parents for their unconditional support. I would also like to thank my sister Mona and all my brothers for their continued love and their interest in my project. 6 Table of Contents Dedication ..........................................................................................................................2 Declaration .........................................................................................................................3 Abstract ..............................................................................................................................4 Acknowledgements............................................................................................................6 List of Figures ..................................................................................................................13 List of Tables....................................................................................................................15 Glossary of Abbreviations ...............................................................................................16 Communications arising from the Thesis ........................................................................18 Published papers ..........................................................................................................18 Oral presentations.........................................................................................................18 Poster presentations......................................................................................................18 Chapter 1: Relevant Anatomy and Physiology................................................................20 1.1 Chapter layout ........................................................................................................21 1.2 Descriptive anatomy of the anorectum and pelvic floor ........................................21 1.2.1 Anorectum.......................................................................................................21 1.2.2 Internal Anal Sphincter (IAS).........................................................................22 1.2.3 External Anal Sphincter (EAS).......................................................................22 1.2.4 The pelvic floor...............................................................................................23 1.3 Nerve supply of the anorectum and the pelvic floor..............................................25 1.3.2 Nerve supply of the anal canal and anal sphincters ........................................25 1.3.3 Nerve supply of the pelvic floor .....................................................................26 1.3.4 Summary of anorectal nerve supply................................................................27 1.4 Neuronal control of intestinal function .................................................................27 1.4.1 The intrinsic enteric system ............................................................................29 1.4.2 The extrinsic nerves to the gut ........................................................................30 1.4.3 Gut reflex motor responses .............................................................................31 1.5 Relevant physiological topics ................................................................................33 1.5.1 Physiology of defecation.................................................................................33 1.5.2 Rectal sensory function...................................................................................34 1.5.3 Rectal compliance ...........................................................................................34 Chapter 2: Faecal Incontinence........................................................................................36 2.1 Chapter layout ........................................................................................................37 2.2 Definitions..............................................................................................................37 7 2.3 Introduction............................................................................................................38 2.4 Epidemiology .........................................................................................................38 2.5 Aetiology................................................................................................................39 2.5.1 Altered stool consistency (diaorrheal states)...................................................40 2.5.2 Inadequate rectal reservoir or compliance ......................................................40 2.5.3 Altered rectal sensory function or motility .....................................................40 2.5.4 Altered sphincter or pelvic floor mechanism..................................................41 2.5.5 Obstetric trauma and its risk factors ...............................................................42 2.6 Grading and classification......................................................................................43 2.6.1 Grading of severity..........................................................................................43 2.6.2 Classification according to the predominant clinical feature..........................44 2.7 Clinical assessment ................................................................................................44 2.7.1 Clinical history................................................................................................44 2.7.2 Clinical Examination.......................................................................................45 2.8 Investigations .........................................................................................................46 2.8.1 Physiological studies.......................................................................................46 2.8.2 Structural Assessments....................................................................................49 2.9 Treatment ...............................................................................................................52
Load more

Recommended publications
  • Sacral Nerve Stimulation for Urinary Voiding Dysfunction and Fecal
    Medical Coverage Policy Effective Date ............................................10/15/2020 Next Review Date ......................................10/15/2021 Coverage Policy Number .................................. 0404 Sacral Nerve and Tibial Nerve Stimulation for Urinary Voiding Dysfunction, Fecal Incontinence and Constipation Table of Contents Related Coverage Resources Overview .............................................................. 1 Biofeedback Coverage Policy ................................................... 1 Electrical Stimulation Therapy and Devices General Background ............................................ 3 Fecal Bacteriotherapy Medicare Coverage Determinations .................. 19 Injectable Bulking Agents for Urinary Conditions and Coding/Billing Information .................................. 19 Fecal Incontinence References ........................................................ 21 INSTRUCTIONS FOR USE The following Coverage Policy applies to health benefit plans administered by Cigna Companies. Certain Cigna Companies and/or lines of business only provide utilization review services to clients and do not make coverage determinations. References to standard benefit plan language and coverage determinations do not apply to those clients. Coverage Policies are intended to provide guidance in interpreting certain standard benefit plans administered by Cigna Companies. Please note, the terms of a customer’s particular benefit plan document [Group Service Agreement, Evidence of Coverage, Certificate of Coverage,
    [Show full text]
  • Smedimnic INFORMATION for PRESCRIBERS Medtronic Interstimo Therapy
    InterStim lBowelenlcvm W141/08 1:40pm Medtronic Confidential US Mlar1elRelease er 4.5 aS6nches (114 mma 152Mm) NuoFO SMedimnic INFORMATION FOR PRESCRIBERS Medtronic InterStimO Therapy Rx only M925905AW3 Rev X Inter~fir Sowan c.ahtm W/l4/0 1:40 M Medtronic Confidential US Mautt Release 4,5x 6inchesa(114 mm x 152 mm) NeurolPO m Medironic * and InlerStim' are registered trademarks and SoftStartStop ' is a trademark of Meduronic, Inc. Additional Information available for the InterStin, Therapy system Documents packaged with this product: * For therapy-specific information, refer to the Indications Insert. * For Information regarding device compatibility, refer to the System Overview and Compatibility Insert - For information on the clinical study resuita for InterStinm Therapy and for a complete summary of adverse events, refer to the Clinical Summary. * For warranty Information, refer to the Limited Warranty and Special Notice Insert Documents packaged with the clinician programmer software application card: *For neurostimulator selection, battery longevity calculations, and specific neurostimulator specifications, refer to the System Eligibility Battery Longevity, Specifications Reference Manuoal. M925905AC03 Rev X InterSdm_ oeIenTOCm B11408 1:40pm Medtronlc Confidential USMat Release 4.5 x inches (114 mm a I5 ramm) NeurolFPROO Contraindications 5 Warnings 5 Electromagnetic interference (EMI) 5 Case Carnage 7 Effects on other implanted devices 7 Precautions 7 Clinician programming 7 Clinician training 9 Patient activities 9 Patient programming
    [Show full text]
  • Medical Policy
    Medical Policy Joint Medical Policies are a source for BCBSM and BCN medical policy information only. These documents are not to be used to determine benefits or reimbursement. Please reference the appropriate certificate or contract for benefit information. This policy may be updated and is therefore subject to change. *Current Policy Effective Date: 5/1/21 (See policy history boxes for previous effective dates) Title: Sacral Nerve Neuromodulation/Stimulation Description/Background Sacral nerve neuromodulation (SNM), also known as sacral nerve stimulation (SNS), is defined as the implantation of a permanent device that modulates the neural pathways controlling bladder or rectal function. This policy addresses use of SNM in the treatment of urinary or fecal incontinence, urinary or fecal nonobstructive retention and chronic pelvic pain in patients with intact neural innervation of the bladder and/or rectum. Urinary and Fecal Incontinence Urgency-frequency is an uncontrollable urge to urinate, resulting in very frequent, small volumes and is a prominent symptom of interstitial cystitis (also called bladder pain syndrome). Urinary retention is the inability to completely empty the bladder of urine. Fecal incontinence can arise from a variety of mechanisms, including rectal wall compliance, efferent and afferent neural pathways, central and peripheral nervous systems, and voluntary and involuntary muscles. Fecal incontinence is more common in women, due mainly to muscular and neural damage that may occur during vaginal delivery. Treatment Treatment using SNM, also known as indirect SNS, is one of several alternative modalities for patients with fecal or urinary incontinence (urge incontinence, significant symptoms of urgency- frequency, or nonobstructive urinary retention) who have failed behavioral (e.g., prompted voiding) and/or pharmacologic therapies.
    [Show full text]
  • Sacral Nerve Stimulation for Urinary Indications
    Sacral nerve stimulation for urinary indications November 2008 MSAC application 1115 Assessment report © Commonwealth of Australia 2008 ISBN 1-74186-790-8 ISBN 1-74186-791-6 ISSN 1443-7120 ISSN 1443-7139 First printed Paper-based publications © Commonwealth of Australia 2008 This work is copyright. Apart from any use as permitted under the Copyright Act 1968, no part may be reproduced by any process without prior written permission from the Commonwealth. Requests and inquiries concerning reproduction and rights should be addressed to the Commonwealth Copyright Administration, Attorney General’s Department, Robert Garran Offices, National Circuit, Barton ACT 2600 or posted at http://www.ag.gov.au/cca Internet sites © Commonwealth of Australia 2008 This work is copyright. You may download, display, print and reproduce this material in unaltered form only (retaining this notice) for your personal, non-commercial use or use within your organisation. Apart from any use as permitted under the Copyright Act 1968, all other rights are reserved. Requests and inquiries concerning reproduction and rights should be addressed to Commonwealth Copyright Administration, Attorney General’s Department, Robert Garran Offices, National Circuit, Barton ACT 2600 or posted at http://www.ag.gov.au/cca Electronic copies of the report can be obtained from the Medical Service Advisory Committee’s Internet site at http://www.msac.gov.au/ Printed copies of the report can be obtained from: The Secretary Medical Services Advisory Committee Department of Health and Ageing Mail Drop 106 GPO Box 9848 Canberra ACT 2601 Enquiries about the content of the report should be directed to the above address.
    [Show full text]
  • Urinary Incontinence Treatment
    Urinary Incontinence Treatment Date of Origin: 07/2002 Last Review Date: 03/24/2021 Effective Date: 04/01/2021 Dates Reviewed: 01/2004, 02/2005, 01/2006, 02/2007, 03/2008, 03/2009, 02/2011, 02/2012, 02/2013, 02/2014, 10/2015, 03/2016, 06/2017, 08/2018, 03/2019, 03/2020, 03/2021 Developed By: Medical Necessity Criteria Committee I. Description A number of procedures have been investigated for the treatment of urinary incontinence, including pelvic floor muscle exercises, behavioral therapy, sacral nerve stimulation, pelvic floor stimulation, surgery, and radiofrequency energy. InterStim Continence Control Therapy is sacral nerve stimulation that involves the implantation, into the lower back, of electrical leads that are in contact with the sacral nerve root. The wire leads extend through an incision in the abdomen and are connected to an inserted pulse generator to deliver controlled electrical impulses. The physician programs the pulse generator and the individual is able to switch the pulse generator on and off. Percutaneous tibial nerve stimulation with Urgent® PC by Uroplasty involves the placement of a fine needle electrode into the lower, inner aspect of the leg, near the tibial nerve. The needle electrode is connected to pulse generator that delivers an electrical pulse to the tibial nerve that travels to the sacral plexus. The sacral plexus is responsible for regulating bladder and pelvic floor function. The treatment protocol is for 12 treatments, once a week. An artificial urinary sphincter is a device that involves an inflatable cuff that fits around the urethra. A balloon regulates the pressure of the cuff and a bulb controls inflation and deflation of the cuff.
    [Show full text]
  • Sacral Nerve Stimulation
    7-2 Sacral Nerve Stimulation Joanna M.Togami and Gamal M. Ghoniem Sacral nerve stimulation (SNS) is a useful tool to have in stress incontinence, and high frequency (200Hz) for the armamentarium for the treatment of voiding dysfunc- urinary retention. A review of trials of functional electri- tion. Since Food and Drug Administration approval, SNS cal stimulation for stress urinary incontinence showed cure has evolved to attain a major role in treating refractory in 18% and improvement in 34% of patients. In the treat- overactive bladder (OAB) and patients with difficult pelvic ment of OAB, maximal electrostimulation cured 20% and floor dysfunction. It has become a viable option in those improved 37% of women with urodynamic detrusor over- patients who failed conservative therapy, but who desire activity incontinence.1 Functional electrical stimulation is alternative therapy before more invasive procedures are of limited value in the treatment of stress incontinence. performed. The technique and the technology have been improved, increasing the safety and efficacy whereas decreasing patient morbidity. Mechanism of Action The precise mechanism of action by which electrical stim- Functional Electrical Stimulation ulation works remains to be proven. It is thought that the efficacy is dependent on stimulation of the afferent nerves Electrical stimulation has been used for a variety of lower that modulate sensory processing of the voiding reflex and urinary tract symptoms including those of OAB and its pathways to the central nervous system. Several voiding painful bladder syndrome. There are mainly two types of reflexes are affected by neuromodulation, and it is useful electrical stimulation: chronic, in which low current is used to review these.
    [Show full text]
  • Non-Invasive Brain Stimulation Techniques for Chronic Pain (Review)
    Cochrane Database of Systematic Reviews Non-invasive brain stimulation techniques for chronic pain (Review) O’Connell NE, Wand BM, Marston L, Spencer S, DeSouza LH O’Connell NE, Wand BM, Marston L, Spencer S, DeSouza LH. Non-invasive brain stimulation techniques for chronic pain. Cochrane Database of Systematic Reviews 2014, Issue 4. Art. No.: CD008208. DOI: 10.1002/14651858.CD008208.pub3. www.cochranelibrary.com Non-invasive brain stimulation techniques for chronic pain (Review) Copyright © 2014 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. TABLE OF CONTENTS HEADER....................................... 1 ABSTRACT ...................................... 1 PLAINLANGUAGESUMMARY . 2 SUMMARY OF FINDINGS FOR THE MAIN COMPARISON . ..... 4 BACKGROUND .................................... 6 OBJECTIVES ..................................... 8 METHODS ...................................... 8 RESULTS....................................... 11 Figure2. ..................................... 12 DISCUSSION ..................................... 24 AUTHORS’CONCLUSIONS . 28 ACKNOWLEDGEMENTS . 29 REFERENCES ..................................... 29 CHARACTERISTICSOFSTUDIES . 37 DATAANDANALYSES. 126 Analysis 1.1. Comparison 1 Repetitive transcranial magnetic stimulation (rTMS), Outcome 1 Pain: short-term follow- up. ..................................... 130 Analysis 1.2. Comparison 1 Repetitive transcranial magnetic stimulation (rTMS), Outcome 2 Pain: short-term follow-up, subgroup analysis: multiple-dose vs single-dose studies. ................
    [Show full text]
  • A Comprehensive View of Electrosleep: the History, Finite Element Models and Future Directions
    City University of New York (CUNY) CUNY Academic Works Dissertations and Theses City College of New York 2014 A Comprehensive View of Electrosleep: The History, Finite Element Models and Future Directions Berkan Guleyupoglu CUNY City College How does access to this work benefit ou?y Let us know! More information about this work at: https://academicworks.cuny.edu/cc_etds_theses/626 Discover additional works at: https://academicworks.cuny.edu This work is made publicly available by the City University of New York (CUNY). Contact: [email protected] 2 Abstract Transcranial Electrical Stimulation (tES) encompasses all methods of non-invasive current application to the brain used in research and clinical practice. We present the first comprehensive and technical review, explaining the evolution of tES in both terminology and dosage over the past 100 years of research to present day. Current transcranial Pulsed Current Stimulation (tPCS) approaches such as Cranial Electrotherapy Stimulation (CES) descended from Electrosleep (ES) through Cranial Electro-stimulation Therapy (CET), Transcerebral Electrotherapy (TCET), and NeuroElectric Therapy (NET) while others like Transcutaneous Cranial Electrical Stimulation (TCES) descended from Electroanesthesia (EA) through Limoge, and Interferential Stimulation. Prior to a contemporary resurgence in interest, variations of transcranial Direct Current Stimulation were explored intermittently, including Polarizing current, Galvanic Vestibular Stimulation (GVS), and Transcranial Micropolarization. The development of these approaches alongside Electroconvulsive Therapy (ECT) and pharmacological developments are considered. Both the roots and unique features of contemporary approaches such as transcranial Alternating Current Stimulation (tACS) and transcranial Random Noise Stimulation (tRNS) are discussed. Trends and incremental developments in electrode montage and waveform spanning decades are presented leading to the present day.
    [Show full text]
  • Surgery and Sacral Nerve Stimulation for Constipation and Fecal Incontinence
    Surgery and Sacral Nerve Stimulation for Constipation and Fecal Incontinence Rodrigo A. Pinto, MD, Dana R. Sands, MD, FACS, FASCRS* KEYWORDS Fecal incontinence Constipation Sphincterplasty Sacral nerve stimulation Fecal incontinence and constipation are two colorectal diseases that have a high incidence requiring specialized treatment when medical options are exhausted. This article briefly discusses the etiology, epidemiology, incidence, and pathology history of constipation and fecal incontinence, followed by a detailed review of the surgical options, including SNS. FECAL INCONTINENCE Fecal continence is a complex bodily function, which requires the interplay of sensa- tion, rectal capacity, and neuromuscular function. Multiple factors, such as cognitive function, stool consistency and volume, rectal distensibility, colonic transit, anorectal sensation, anal sphincter function, and anorectal reflexes, can influence a patient’s continence.1 Fecal incontinence affects approximately 2% of the population and has a prevalence of 15% in elderly patients.2,3 This disorder is a debilitating condition that can be personally and socially incapacitating. Incontinence is considered complete when the patient loses control of solid feces and partial when the patient has inadvertent soiling or escape of liquid or flatus. Browning and Parks4 proposed criteria to stage fecal incontinence as follows: A, normal continence; B, incontinence to flatus; C, no control to liquid or flatus; D, continued fecal leakage. Subsequently, many grading scales have been proposed, and most consider the frequency of incontinence episodes as the most important item. Some scales,5,6 which included urgency, clean- ing difficulty, use of pads, and impact on quality of life, are considered more complete. Many authors have proposed scales for fecal incontinence.
    [Show full text]
  • Corporate Medical Policy Sacral Nerve Neuromodulation/Stimulation for Pelvic Floor Dysfunction
    Corporate Medical Policy Sacral Nerve Neuromodulation/Stimulation for Pelvic Floor Dysfunction File Name: sacral_nerve_neuromodulation_stimulation_for_pelvic_floor_dysfunction Origination: 5/2000 Last CAP Review: 11/2020 Next CAP Review: 11/2021 Last Review: 11/2020 Description of Procedure or Service Sacral nerve stimulation (SNS), also referred to as sacral nerve neuromodulation (SNM), involves the implantation of a permanent device that modulates the neural pathways controlling bladder or rectal function. This policy addresses use of SNS in the treatment of urinary or fecal incontinence, fecal non - obstructive retention, and chronic pelvic pain in patients with intact neural innervation of the bladder and/or rectum. Urge incontinence is defined as leakage of urine when there is a strong urge to void. Urgency - frequency is an uncontrollable urge to urinate, resulting in very frequent, small volumes. Urgency- frequency is a prominent symptom of interstitial cystitis (also called bladder pain syndrome.) Urinary retention is the inability to completely empty the bladder of urine. Fecal incontinence can arise from a variety of mechanisms, including rectal wall compliance, efferent and afferent neural pathways, central and peripheral nervous systems, and voluntary and involuntary muscles. Fecal incontinence is more common in women, due mainly to muscular and neural damage that may occur during vaginal delivery. Sacral nerve stimulation treatment is one of several alternative modalities for patients with urinary or fecal incontinence (urge incontinence, significant symptoms of urgency-frequency, nonobstructive urinary retention) who have failed behavioral (eg, prompted voiding) and/or pharmacologic therapies. The SNM device consists of an implantable pulse generator that delivers controlled electrical impulses. This pulse generator is attached to wire leads that connect to the sacral nerves, most commonly the S3 nerve root.
    [Show full text]
  • Sacral Nerve Stimulation for Urinary Incontinence (NCD 230.18)
    UnitedHealthcare® Medicare Advantage Policy Guideline Sacral Nerve Stimulation for Urinary Incontinence (NCD 230.18) Guideline Number: MPG269.07 Approval Date: January 13, 2021 Terms and Conditions Table of Contents Page Related Medicare Advantage Policy Guideline Policy Summary ............................................................................. 1 • Electrical Nerve Stimulators (NCD 160.7) Applicable Codes .......................................................................... 1 References ..................................................................................... 2 Related Medicare Advantage Coverage Summary Guideline History/Revision Information ....................................... 3 • Incontinence: Urinary and Fecal Incontinence, Purpose .......................................................................................... 3 Diagnosis and Treatments Terms and Conditions ................................................................... 3 Policy Summary See Purpose Overview Sacral nerve stimulation is covered for the treatment of urinary retention, urinary urge incontinence, urgency-frequency syndrome. Sacral nerve stimulation involves both a temporary test stimulation to determine if an implantable stimulator would be effective and a permanent implantation in appropriate candidates. Both the test and the permanent implantation are covered. Guidelines The following limitations for coverage apply to all three indications: Patient must be refractory to conventional therapy (documented behavioral, pharmacologic
    [Show full text]
  • Bladder and Sacral Nerve Stimulation
    POLICY AND PROCEDURE MANUAL Policy Title: Bladder and Sacral Nerve Stimulation Policy Number: G.08 Primary Department: Medical Management NCQA Standard: N/A Affiliated Department(s): N/A URAC Standard: N/A Last Revision Date: 05/2018 Next Review Date: 07/2020 Revision Dates: 06/2014; 02/2015; 04/2015; 06/2016; 06/2017; Review Dates: 09/27/2013; 06/27/2014; 05/2018 03/27/2015; 06/26/2015; 06/24/2016; 06/28/2017; 06/27/2018; 6/26/2019 Effective Date: 11/01/2013 Applicable Lines of Business:☒MeridianCare ☒MeridianHealth ☒MeridianComplete ☒MeridianChoice Applicable States: ☐All ☒MI ☒IL ☐OH ☐_______ ☐________ Applicable Programs: ☒All ☐Other ________________________ Policy is to be published: Internally Only ☐ Internally & Externally ☒ Definitions: Overactive Bladder A term used to describe urinary urgency, usually with urinary frequency and nocturia, with Syndrome (OAB) or without urgency urinary incontinence. Percutaneous Tibial These stimulators deliver retrograde access to the sacral nerve through percutaneous Nerve Stimulator (PTNS) stimulation of the tibial nerve Policy: There are a number of devices available to induce emptying of the urinary bladder by using electrical current which forces the muscles of the bladder to contract. These devices (commonly known as bladder stimulators or pacemakers) are characterized by the implantation of electrodes in the wall of the bladder, the rectal cones, or the spinal cord. While these treatments may effectively empty the bladder, the safety issues involving the initiation of infection, erosion, placement, and material selection have not been resolved. Further, some facilities previously using electronic emptying have stopped using this method due to the pain experienced by patients.
    [Show full text]