Pudendal Neuromodulation in Spina Bifida Patients With Neurogenic Bladder and Bowel Dysfunction
Journal of Urology
INTRODUCTION AND OBJECTIVE: Spina bifida is a congenital defect resulting in incomplete closure of the neural tube in the sacrum. It is the primary cause of congenital urinary dysfunction with symptoms ranging from frequency, urgency and urge incontinence to urinary retention. Patients often have concomitant bowel dysfunction with both constipation and fecal incontinence resulting in a significantly decreased quality of life. Because of the resulting sacrococcygeal deformity typical techniques for placement of a tined lead at the S3 foramen are ineffective. Neuromodulation has long been used to treat bladder and bowel dysfunction and evidence suggests that pudendal neuromodulation has a role in the treatment of symptoms secondary to spinal pathology. Our objective was to assess the effectiveness of pudendal neuromodulation in treating bowel and lower urinary tract symptoms (LUTS) in spina bifida. METHODS: We investigated the effect of pudendal nerve stimulation on LUTS and bowel symptoms in four spina bifida patients. All four patients failed behavioral modification and anticholinergics. They underwent staged neuromodulation with placement of a tined lead at the pudendal nerve for the treatment of refractory LUTS and bowel symptoms. Relevant medical history, physical exams, symptoms prior to treatment and symptom improvement were assessed. RESULTS: One male and three female patients with a mean age of 45.8 years (39-53) were included in the study. Mean follow-up was 68 months (43-83). All three females had urgency, frequency, urge incontinence and fecal incontinence at baseline. At the most recent follow-up, all have maintained a clinical improvement of more than 50%for all symptoms compared with baseline. The male patient, with urinary retention prior to treatment, reported improved bladder sensation yet did not have improvement in intermittent catheterization volumes. CONCLUSIONS: A 2022 SUFU white paper described the potential risk of dementia in anticholinergic dependent spina bifida patients. The 2021 AUA/SUFU guidelines recommended against sacral neuromodulation in this population due to sacral deformities. Pudendal neuromodulation is a promising treatment for patients with both bowel and bladder symptoms secondary to spina bifida. More research is needed to elucidate this potential and will help to expand the indications for pudendal neuromodulation and neuromodulation in potential alternative locations.
Eisner H, Zwaans B, Padmanabhan P, Peters K. Pudendal neuromodulation in spina bifida patients with neurogenic bladder and bowel dysfunction. J Urol. 2023 Apr;209(4S):e706. doi:10.1097/JU.0000000000003300.09