Sacral Neuromodulation for Overactive Bladder


Dr. Dean S. Elterman, MD, MSc, FRCSC,1 Harkiran K. Sagoo, BSc(Hons),2

1Attending Urologic Surgeon, Toronto Western Hospital, University Health Network, Assistant Professor, Division of Urology, Department of Surgery, University of Toronto, Toronto, ON.
24th Year Medical Student at GKT School of Medicine, King's College London, U.K.


Abstract: Sacral Neuromodulation (SNM) is a FDA-approved minimally invasive surgical therapy offered as a third-line treatment for refractory overactive bladder (OAB). Studies report improvements in continence, mean number of voids/day, quality of life, depression and sexual function in patients receiving SNM compared to medical therapy, with treatment success sustained long-term and with few adverse events. SNM is recommended by CUA and AUA guidelines in the treatment of OAB in carefully selected patients.
Key Words:Neuromodulation, Neurostimulation, Overactive, Bladder, Incontinence.

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Sacral neuromodulation should be offered as third-line treatment for patients with overactive bladder symptoms refractory to conservative/behavioural and/or pharmacological treatment.
Sacral neuromodulation is a minimally invasive procedure that may be offered to carefully selected patients with severe refractory overactive bladder that are willing to undergo a surgical procedure.
Sacral neuromodulation activates inhibitory sympathetic neurons using low-amplitude electrical stimulation of S3 afferent nerve roots to prevent detrusor contraction.
A prospective, randomized multi-center trial (level 1 evidence) reported improvements in incontinence, mean number of voids/day, quality of life, depression and sexual function in patients receiving sacral neuromodulation compared to standard medical treatment.
Adverse events/complications associated with SNM use include: pain at the implantation site, lead migration, wound-related complications, bowel dysfunction, infection, and generator problems.
Sacral neuromodulation is a FDA-approved minimally-invasive surgical therapy used as third-line treatment of overactive bladder symptoms/refractory overactive bladder. It is carried out in two stages, the first (evaluation) stage involves insertion of a temporary generator to assess clinical efficacy, and the second stage involves insertion of a permanent neuromodulator implant in patients that have demonstrated >50% improvement in symptoms during the evaluation stage.
Evidence from randomized, controlled trials, prospective multicenter, prospective single-center and retrospective studies demonstrates clinical efficacy of SNM in reducing symptoms of overactive bladder in these patients and therefore SNM is recommended by CUA and AUA guidelines in the treatment of overactive bladder in carefully-selected patients, as the risks of the procedure outweigh the burdens of the overactive bladder syndrome.
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Behavioural Training for Urge Incontinence

Behavioural Training for Urge Incontinence



A common cause for distress in older women, urge incontinence is a condition that begs for effective treatment. Urge incontinence, the loss of urine due to involuntary bladder contractions, is the most common type of incontinence in individuals older than 60 but is frequently suffered in silence due to its associated stigma. While the condition is frequently treated with drugs to block unwanted contractions, behavioural training may be an equally effective management strategy with fewer side effects.

In a prospective randomized trial, 222 women aged 55 to 92 with urge incontinence or mixed incontinence with urge as the predominant pattern were studied to determine the effect of behavioural training with and without the assistance of biofeedback. Patients were randomized to behavioural treatment with biofeedback, behavioural treatment with verbal feedback or a self-administered behavioural training program.

In the first group, a three-balloon probe was inserted anally to measure anal sphincter responses to abdominal pressures and to help patients identify and contract pelvic floor muscles while maintaining abdominal relaxation. Patients were taught to relax upon experiencing urgency sensations and to prevent urine escape via controlled muscle contraction. The second group was given the same behavioural instruction as the first, but was offered verbal feedback based on vaginal palpation rather than biofeedback. The control group was given a written manual with the same instructional content as that used in the second group, but had no access to professional equipment or expertise. The patients in all three groups were recommended to perform a daily routine of 45 pelvic floor muscle exercises. The training programs spanned eight weeks, after which point a two-week post-treatment bladder diary was completed.

Following treatment, the biofeedback and verbal feedback groups documented a 63.1% and 69.4% mean percentage reduction in accident frequency, respectively, whereas the control group lagged slightly at 58.6%. Covariance analysis indicated that the three groups were not significantly different. However, the finding that patients who completed a post-treatment cystometrogram had bladder capacity increased by an average of 47.8mL in the biofeedback group, 63.2mL in the verbal feedback group and 37.0mL in the control group, was significant. Most dramatic of all was the discrepancy in patient satisfaction and perceptions of progress. While the majority of participants in the two test groups described their condition as "much better", only 30.8% of patients in the control arm claimed similar success.

Given the similarity in results from the two treatment groups, the use of behavioural training may generally be favoured over behavioural training with biofeedback due to decreased cost and invasiveness. While the control group also displayed a reduction in incontinence episodes, the perception of relative failure in this group may be enough to render this self-teaching method inferior, given the probable relationship between satisfaction and reduction of future accidents.


  1. Burgio KL, Goode PS, Locher JL, et al. Behavioral training with and without biofeedback in the treatment of urge incontinence in older women. JAMA 2002;288:2293-9.

Stress Urinary Incontinence--Part II of V

Stress Urinary Incontinence--Part II of V


Sonya Lytwynec, RegN, BScN
Nurse Clinician, Southwestern Ontario Regional Geriatric Program: Continence Outreach

Stress urinary incontinence (SUI) is one of five types of incontinence.1 The assessment and therapeutic interventions associated with stress incontinence will be reviewed in this second article of a five-part series on Urinary Incontinence.

SUI is defined as urine loss coincident with an increase in intra-abdominal pressure in the absence of a detrusor muscle contraction or an over-distended bladder.2 SUI is a term used in reference to symptoms, physical findings or conditions. Coughing, sneezing, laughing, lifting, or bending over along with simultaneous urine loss often indicates SUI. However, in complex or unresolved cases, urodynamic testing may be beneficial to differentiate between SUI and other types such as urge incontinence.

Prevalence studies report variable results according to definition and design. Subjective reports of SUI in community-dwelling elderly women (65 years of age or older) ranged between 12% and 17%, while urodynamic studies at a urological clinic estimated prevalence rates of SUI at 16% for females and 2% for males.3

SUI in males is commonly the result of intrinsic sphincter deficiency (ISD) post prostatectomy.