Sacral Neuromodulation For Urge Incontinence

Sacral neuromodulation is a highly effective, specialist treatment for urge incontinence (and is also used for other conditions such as bladder pain).

The principle behind it is using electrical currents to reset the faulty nerve patterns which are the cause of your bladder overactivity.

BPC consultant Mohammed Belal is the West Midland regional lead consultant for sacral neuromodulation, receiving referrals for patients who are being considered for the treatment and training other clinicians in carrying it out.

What does the treatment involve?

The first step is to have a simple test procedure to see whether neuromodulation is effective for you. The sacral nerves are located in the lower back. Under a local or short general anaesthetic, the surgeon uses a small needle to place a thin wire in contact with your sacral nerves. The other end of the wire is taped to the outside of your back and connected to a temporary stimulator control unit, which is worn on your belt. This temporary stimulator is worn for three weeks to assess your response. The approach works well for approximately 70 per cent of patients.

If you find the treatment effective, you will be asked to come into hospital again to have a permanent implant. This a much smaller device – the size of a £2 coin – which is implanted under the skin and fat of the lower back so it cannot be felt. You will not have to have anything attached to your back or any external device. A control unit, the size of a mobile phone, is used to change and control the frequency of electrical signals and you can keep this at home.

The procedure is carried out under general anaesthetic, although you will probably be able to return home on the same day.

How does the treatment work?

This treatment is sometimes referred to as the ‘pacemaker for the bladder’. A traditional cardiac pacemaker is a device implanted inside the body which and sends electrical currents to the heart, correcting faulty heart rhythms.

In the ‘overactive bladder’ the sacral nerves send unwanted messages to the bladder, causing it to contract suddenly (urgency) and empty without due warning (urge incontinence). Sacral neuromodulation works be interrupting this ‘faulty circuit’ and restores normal communication between the nerves, brain and the bladder.

Unlike Botox, there is no need for repeat treatment, and there is little risk of requiring catheters to empty your bladder. The battery in the permanent implant is effective for up to seven years.

How does it feel?

The implant is very small and placed underneath the fat of the lower back/upper buttock area. The surgeon makes a small incision of about 3cm to insert the device during surgery, so recovery is quick and straightforward. The device is cushioned by the body’s fat and so you will not be aware that you have any implant in that area. Patients say they are sometimes aware of the device when they lie in certain positions, but they do not report feeling any discomfort.

The electrical stimulation is kept below detectable levels and the patient is not aware of the stimulation unless the pulses are turned up. There is usually an initial period of the first few weeks after the implant is inserted when you get used to the device and find the right level for you.

What is the evidence for this treatment?

Sacral neuromodulation was first described in 1982 and now more than 20 years of accumulated evidence establishing its effectiveness and safety. It was approved by NICE (National Institute for Health and Clinical Excellence) in 2003 and is widely used in Spain, Holland and Germany. However, the technique has not been widely available in the NHS due to cost and limited expertise available in the UK.