September 10, 1999
Neural Stimulation is a therapy which can be effective for patients with pain and voiding dysfunction, particularly if anti-microbial or anti-inflammatory based therapies are unsuccessful. I have no personal experience with the technique, which is quite technically involved, but here is a synopsis provided to me by Dr. Stuart Chalfin, a urologist in our community with considerable experience. I have started to refer patients to him, but it is too early to tell how effective this might be for CPPS patients. If anyone is interested in more information, his office number for appointments is (562) 598-6166.
Please don't email me for more info on this technique or for a list of people in your area who perform it: what I have posted here is all I know.
Daniel Shoskes MD
Institute for Male Urology http://www.urol.com
Sacral Nerve Root Stimulation
Over one million people in the United States alone have problems with frequent voiding and unstable bladder disease. A recent study in Germany estimated that ten per cent of the adult female population suffered from this disorder. Bladder retraining, pelvic floor exercises, biofeedback, and anti-cholinergic drug therapy (oxybutynin,tolterodine) are effective measures to treat this problem. However, some patients remain resistant to therapy. For this group of patients, unilateral sacral nerve stimulation offers a safe and nondestructive alternative. It has rapidly replaced major and often unsuccessful surgery as the primary form of therapy in this difficult group of patients. It's usage for chronic prostatitis and interstitial cystitis is growing.
The therapy works by applying chronic electrical stimulation to sensory nerves that supply the bladder, rectum and pelvic floor. Overactive reflexes that drive the frequency and incontinence are "shut off" by this therapy. The bladder once again can remain quiet until the appropriate time to void is reached. The therapy also works for some syndromes of urinary retention. These patients are unable to void and are forced to pass catheters through their urethra in order to void. This less common condition is also known as "Fowlers Syndrome".
Candidates for the therapy can first be tested in the office with a technique called per-cutaneous nerve evaluation. (P.N.E.) Utilizing a local anesthetic, the doctor can place a wire electrode through the skin and holes or foramen in the sacrum. (The area just above the crease of the buttocks) This leaves the electrode in an area where it is in close contact with the nerves that run in and out of the bladder and pelvis. The technique is very safe and there have not been any long term complications associated with it. After a special dressing and tape are applied, the wire is connected to a stimulator box. The patient can then go home and function normally with the device for a period of three days to two weeks. At the end of the test period, both the patient and doctor can determine if the therapy is successful. Thus the patient can take a safe "test drive" with the device prior to any permanent implantation. There are very few treatments in medicine that offer this advantage.
Patients who are candidates for a permanent implant are admitted overnight after a small surgery. The surgery is performed through two incisions on the buttocks. A wire electrode and a small generator similar to a pacemaker are implanted. The device is activated via a computer and radio transmitter within 48 hours in the doctor's office. The patient can then control the device with a hand held transmitter that looks and functions very similar to a television remote control.
Long term success has been excellent. In a multi-center, randomized prospective clinical trial for this therapy, at six-month follow-up, 75% of implanted patients had a reduction in frequency of leaking episodes of 50% or greater and 47% of the implanted patients were dry. At 12-month follow-up, 79% of implanted patients had a reduction in frequency of leaking episodes of 50% or greater and 45% of the implanted patients were dry. This treatment is approved for patients with frequent voiding and results have also been excellent in this group of patients. Currently, sufferers of interstitial cystitis, chronic prostatitis and other pelvic pain syndromes are undergoing clinical trials to determine the success of neurostimulation this group of patients.
Neurostimulation is an exciting, newly approved therapy for chronic voiding problems in both men and women. Now and in the future, it will increasingly be utilized to treat patients with these disorders.
Stuart A. Chalfin, M.D.
Associates in Urology
Los Alamitos, California
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