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A pacemaker for your bothersome bladder: if other treatments fail, neuromodulation may ease urinary symptoms that persist after treatment for enlarged prostate.

You've undergone medical treatment for benign prostatic hyperplasia (BPH), and your doctor says your enlarged prostate is no longer obstructing the flow of urine from your bladder.

Yet, you still feel an urgent need to urinate, and you're still making too many trips to the bathroom. The treatment has cured your problematic prostate but not your bothersome bladder. And the treatments your physician prescribed to address these lingering symptoms aren't helping.

In these instances, a procedure known as sacral neuromodulation may ease bladder overactivity and provide relief.

"I tell patients to think of it as a pacemaker for the bladder," says Khaled Fareed, MD, with Cleveland Clinic's Glickman Urological & Kidney Institute. "It basically inhibits bladder overactivity and regulates bladder contraction by stimulating the nerves."

The procedure can help, but it also carries risks and should be considered only after exhausting other, more conservative therapies.


An enlarged prostate can obstruct the bladder outlet, causing most men with BPH to experience increased urinary urgency or frequency. BPH medications can relax the smooth muscles of the prostate and bladder neck and shrink the prostate to reduce symptoms. Doctors also may prescribe drugs such as Detrol or Vesicare to ease urinary urgency or frequency. These medications may be used in combination with biofeedback, in which you learn to train the muscles used to control urine flow.


Still, in some men, the nerves of the bladder do not settle down, and they experience symptoms even after their prostate size has been reduced and they've tried these other therapies. For them, sacral neuromodulation may be an option.

In this treatment, marketed as InterStim, a small electrical generator, or neurostimulator, is implanted just under the skin of the upper buttock. The device sends an electrical current along a timed lead, or wire, placed in contact with the nerves exiting the base of the spine (sacrum) that control the bladder and pelvic floor muscles.

To determine your candidacy for sacral neuromodulation, you'll undergo tests to measure your urine flow, bladder contractility or strength, and, possibly, a cystoscopy, in which a doctor inserts a tiny scope through the urethra to view the bladder. Then, you'll be fitted with a temporary lead and wear an external neurostimulator tor a week to see it your symptoms improve. If so, the external generator unit will be replaced by an internal, totally concealed implant. The outpatient procedure is done under local anesthesia or monitored anesthesia care ("twilight" sleep).

The neurostimulator has a battery life of about five years, after which the implant must be replaced. The metal in the device may preclude you from undergoing magnetic resonance imaging (MRI) of the back. And, it also may set off metal detectors, so carry an identification card to inform security personnel about your implant.

Dr. Fareed advises all men to document their urinary patterns over a three-day period before the procedure, to compare them before and after treatment. He also recommends waiting at least six months after successful therapy for BPH before undergoing sacral neuromodulation, "to give the bladder a chance to settle down."


After surgery, you'll meet with a representative from the device manufacturer to program the neurostimulator and, if necessary, make any adjustments. Dr. Fareed follows up with his patients 12 weeks afterward to monitor their progress. "I've seen excellent results with the InterStim," he says.

Sacral neuromodulation is not without side effects or potential complications. The implant procedure carries a risk of infection. You'll be sore shortly after the procedure, but a low percentage of patients may continue to have chronic pain, Dr. Fareed says. In about 6 percent of patients, the lead moves from its original location against the sacral nerves and must be repositioned to produce the desired effects, he adds. Less commonly, the treatment can cause bowel or urinary problems that may potentially be corrected by adjusting the neurostimulator's settings.

"If reprogramming reprogramming or changing the settings doesn't improve the side effects, or if there is an infection, the device will have to come out," Dr. Fareed says.


Dr. Fareed cautions that although sacral neuromodulation is a minimally invasive procedure and sometimes succeeds when other treatments have failed, "It's not for everybody, and it's for a very select group of patients. ... Once candidacy is established, the risk and benefits and the alternatives should be discussed with the patient, and he should know what to expect and what to look for."


* Before considering sacral neuromodulation, make sure your BPH has been successfully treated and that you've exhausted all conservative therapies.

* Find out if your insurance provider covers the cost of sacral neuromodulation.

* Before the procedure, keep a voiding diary, documenting how many times you urinated, how much, and how many urgency and incontinence episodes you have daily.

* Tell your doctor about any signs of infection (fever, excessive local pain) and any change in urinary or bowel function after the procedure.

* Inquire as to the number of neuromodulation procedures undertaken by your physician, as well as his or her success rate and complication rate.
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Title Annotation:UROLOGY
Publication:Men's Health Advisor
Date:Nov 1, 2012
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