Urology - Sacral Neuromodulation

The purpose of this leaflet is to provide you with information you may need when considering treatment with sacral neuromodulation (SNM).

Who are the members of the multi-disciplinary team?

The team is made up of a small group of practitioners who specialise in bladder conditions and work together to help manage and treat your bladder symptoms.

The team includes:

Mr Chris Betts – Consultant Urologist
Mrs Emma Foster – Consultant Urologist
Mrs Kate Burnett – Staff Grade in Urology
Mr Nicholas Fletcher – Urology Surgical Care Practitioner
Sister Alice Phillips – Urology Specialist Nurse
Sister Nicola Telford – Urology Specialist Nurse

What is sacral neuromodulation (SNM)?

Sacral neuromodulation is a nerve stimulation therapy used to treat a variety of urological conditions including the symptoms of an overactive bladder and urinary retention (the bladders inability to empty).

Symptoms of an overactive bladder can include urge incontinence (involuntary loss of urine associated with a sudden or strong urge to pass urine) and urgency-frequency (an uncontrollable urge to urinate that results in voiding small, frequent amounts of urine).
 
Sacral neuromodulation can help improve bladder function by stimulating the sacral nerve with mild electrical pulses. The sacral nerve controls your bladder and the muscles related to urinary function. If there is a problem with the communication between the sacral nerve and the brain you may have limited control over your bladder function.

Sacral neuromodulation is only considered when other treatment options such as lifestyle modifications, behaviour techniques and drug therapy have failed. Sacral neuromodulation is unlikely to completely ‘cure’ your urinary symptoms; however, it may reduce your symptoms to a manageable level. Unfortunately, not all patients are suitable for this treatment and alternative options may be discussed.

If you have been referred from another hospital and SNM therapy is not appropriate for you then you will be referred back to your local hospital.

How will I know if I am a suitable candidate for sacral neuromodulation?

You will be reviewed in the urology outpatient's department by one of the urology team who will assess your suitability for sacral neuromodulation. During the consultation we will obtain your urological history to gain an insight into your bladder function.
Urodynamic studies will normally have been undertaken prior to this consultation but sometimes it is necessary to repeat these studies. During the consultation you will be given the opportunity to ask any questions.

What is the next step?

There are two stages to sacral neuromodulation. The trial phase and the permanent implant phase.

What should I expect from the trial phase?

The trial phase is used to measure the efficacy of neuro stimulation and it is the only way of gaining an indication as to whether SNM may work for you. If it is decided that sacral neuromodulation is a suitable treatment option, then you will be listed for a trial device to be inserted. You will also be given a bladder diary so we can assess your symptoms before and after the trial. It is important to complete an accurate bladder diary prior to the trial as you will need to bring this along to your appointment as we may not be able to proceed without this. You will be given a date to attend hospital. The trial insertion is a day case procedure performed in the Urology Outpatient Department. A thin wire is inserted through the skin and alongside the nerves (sacral nerves) in your very lower back. These wires will be covered by a dressing and attached to a small external device (external neurostimulator – ENS) that you wear as a belt (see image). The temporary wire is held in place by the dressing and so it is important that you keep the dressing and the device dry at all times.

The dressing should not be removed. Therefore, we advise you not to take a bath and be careful when washing during the trial phase.

You should also avoid intense physical activity, bending, stretching or lifting heavy objects during the trial phase as it could displace the wires.

Before you are discharged home from the Urology Department, the device will be activated and you will be shown how to control the strength of the impulse. You will be seen back in the urology outpatient department 10 – 14 days after the procedure for trial phase evaluation. During the trial phase, it is important that you complete a bladder diary to record your bladder symptoms.

What happens at the trial phase evaluation?

The temporary device will be removed in clinic 10-14 days after insertion. During the consultation we will review your bladder diary and symptoms. For the trial device to be deemed a success we would aim to see at least a 50% improvement in your symptoms. If the trial has been successful, you will be discussed at the SNM multidisciplinary team meeting and you may be offered a permanent implant device. If you are proceeding with a permanent device then you will be shown the current Sacral Neuromodulators available and you will be asked to decide which is most suitable for your needs. You will then be asked to attend pre-op assessment and you will be contacted with a surgery date.

How to complete your bladder diary

You will be asked to complete a bladder diary before and during the trial phase. It is important to complete the diary accurately to help the urology team evaluate whether sacral neuromodulation is the right treatment option for you. Each time you urinate or experience bladder symptoms try to answer these questions in your bladder diary:

• Urine volume voided (if possible)
• Urine volume measured by catheter (only patients who use a catheter)
• Leaking episodes (estimate the amount of leakage)
• Change of continence pad (if appropriate)
• Did you feel empty after voiding or leaking?
• Degree of urgency prior to voiding

What happens during the permanent implant phase?

The procedure is similar to the trial phase. You will receive a date to attend hospital and the procedure will be done as a day case (i.e. you will go home the same day as your surgery). The permanent procedure is performed under a general anaesthetic. A permanent thin wire (electrode) will be implanted close to the nerves in the lowest part of your back. The wire is then connected to the small neurostimulator which will be placed under the skin in your upper buttock. You will be discharged home with the device turned off to allow the wound to heal. You will receive an appointment to be seen in the urology outpatients department approximately 2-4 weeks after the surgery to have the device switched on.

You will be given a handheld patient programmer that will be set up with your own individualised programmes. Teaching will be given on how to use this which will allow you to turn the device on and off as well as adjust the level of stimulation.

We strongly advise that the handheld patient programmer (and if applicable recharger) is placed onto your home insurance as the NHS will not replace a lost or broken device.

What does the electrical stimulation feel like?

Most patients describe a slight pulling, tingling or a tapping sensation in the pelvic area. The stimulation sensation will vary from one person to another, but it should never be painful and the level of stimulation can be easily adjusted.

Some patients do experience pain or an unusual sensation down one leg when the device is switched on. This can usually be stopped or reduced by alteration of the stimulation strength and we can help with this.

What happens next?

After the device has been turned on and adjusted to meet your needs, you will be reviewed in the telephone SNM clinic in 2 - 4 months. You will be given contact numbers for the urology specialist nurses should you have any problems or questions. After the implantation we would arrange to review you annually to monitor your progress, adjust the programmes as needed and check the battery life. When the battery power is low you may notice deterioration in your urinary symptoms and a small operation will be needed to replace the battery. This will require a general anaesthetic and is performed as a day case procedure.

What are the risks of surgery?

All surgical procedures come with potential risks and side effects. The most commonly reported side effects of sacral neuromodulation include – wound infection, bruising, pain or numbness at implant site, leg pain and change in bowel habit. Less commonly there can be mechanical problems with the device such as lead movement, lead breakage and internal technical problems with the neurostimulator. There are also risks associated with having a general anaesthetic and these will be discussed with you. Should the device have to be removed; in about 1% of removals a small portion of wire can remain inside you. This is very rarely a problem, but you will be informed if this has happened.

What precautions do I need to know about?

If you have any other medical treatments or tests, you should inform your medical professional that you have an SNM device. Most medical procedures should not affect your device; however, the following procedures/treatments may be harmful – implantable heart defibrillators/pacemakers, lithotripsy (kidney stone treatment), radiation therapy and radiofrequency/ microwave ablation.

Due to possible damage to the device and injury to yourself, you cannot have MRI scans with certain neurostimulators. If an MRI scan is absolutely necessary and your device is not compatible, then the device will need to be removed before the scan.
However, all new permanent devices are now MRI compatible.

Sacral neuromodulation is not licenced in pregnancy and therefore if you were to become pregnant the device would need to be turned off for the duration of the pregnancy.

When travelling, please ensure you have your patient identification card with you to present to airport security. Full airport guidance will be provided at your activation appointment dependant on your device.

It is recommended that you keep your patient programmer with you at all times as some neurostimulators can occasionally cause an increase in stimulation or turn off your device when walking through shop security theft detectors.

Significant weight loss or weight gain may affect the battery placement. This may require surgery to reposition the battery.

Living with your neurostimulator

A patient with a permanent sacral nerve stimulator should be able to do most of the activities that they did before the implantation. There are some activities which may cause discomfort or affect your neurostimulator. Activities that include sudden excessive or repetitive bending, twisting, bouncing or stretching can cause parts of your implanted system to fracture or move out of place. This can result in loss of stimulation or intermittent stimulation.

Activities that are probably best avoided:

• Any activity that involves the movements as described above
• Gymnastics
• Mountain biking
• High impact sports
• Diving below 10m of water
• Horse riding can be a problem

Activities you can continue:

• Sexual intercourse
• Running
• Jogging
• Walking
• Swimming
• Road biking

Where can I get more information?

National Institute for Health and Care Excellence (NICE) Guidelines
https://www.nice.org.uk/guidance/ipg64/resources/sacral-nerve-  stimulation-for-urge-incontinence-and-
urgencyfrequency-52774280424133

Medtronic Website
https://www.medtronic.com/en-us/l/patients/treatments- therapies/treatment-pathway/how-interstim-therapy-works.html

British Association of Urological Surgeons
https://www.baus.org.uk/

Axonics NICE Guidance
https://www.nice.org.uk/advice/mib164/chapter/The-technology
Axonics Website: https://www.axonics.com