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Purpose of Review: In this review, we discuss the current literature concerning the use of patient education interventions for the improvement of outcomes and patient experience during third-line treatment for overactive bladder. Recent Findings: There are only a few prospective studies in the past decade which examine the role of patient education interventions in sacral neuromodulation and intradetrusor onabotulinum toxin treatments; these studies focus on the ability of the interventions to improve patient understanding and satisfaction around the procedure. Summary: Evidence for the use of patient education to optimize third-line overactive bladder therapies is scarce, but results show promise for using these types of interventions to enhance the patient experience. [ABSTRACT FROM AUTHOR]

Overactive bladder (OAB) is a syndrome of urinary urgency, usually accompanied by frequency, nocturia, and sometimes urinary urgency incontinence. There are many guidelines for the OAB treatment which are constructed on a stepwise fashion starting from the least invasive to the more invasive therapy. The emergence of third-line therapy (AUA/SUFU guidelines) has resulted in significant decrease of more invasive surgery and improved patients’ quality of life. The aim of a clinical pathway is to improve the quality of care, reduce risks, increase patient satisfaction, and increase the efficiency in the use of resources. The available options for the third-line OAB treatments include intravesical injection of botulinum toxin A, percutaneous tibial nerve stimulation (PTNS), and sacral nerve stimulation (SNS). The available evidence confirms that all three treatment approaches are well tolerated and effective, although only botulinum toxin type A (BoNTA) and SNS can achieve nearly a cure of urgency urinary incontinence (UUI). The choice among the different third-line treatment depends on patient preference, availability, and local expertise. The application of these pathways can improve incontinence care by letting physicians adequately communicate with patients and select individualized therapy at an early stage especially for elderly patients.

Purpose of review: Sacral neuromodulation remains an effective therapy for multiple conditions and both the technology and implant techniques have evolved over more than two decades. Understanding of the ideal conditions for testing and administration of the therapy continue to progress as well, though considerable controversy still exists. This review seeks to clarify the current knowledge and opinion surrounding types of neuromodulation testing, what constitutes an optimized lead and best practices for maximizing therapeutic success. Recent findings: There are distinct advantages and disadvantages to each method of sacral neuromodulation testing that should be individualized to each patient. While motor response during lead implantation may be more reliable and even necessary, an approach which balances both motor and sensory data may be advantageous. Optimized lead placement, though not conclusively proven to offer definite advantages, remains a laudable goal for most implantations. Summary: Sacral neuromodulation remains an important therapy for patients with pelvic voiding and elimination dysfunction. Important considerations including office-based or staged testing, motor or sensory prioritization, and the importance of lead optimization remain debatable. However, there remain important lessons that can influence the likelihood of successful therapy. Although there is still work to be done, we are continuing to strive for improvement in patient outcomes as a result of optimized lead placement in sacral neuromodulation. [ABSTRACT FROM AUTHOR]

Purpose of Review: Current literature regarding the role of neuromodulation for the treatment of pelvic pain will be addressed with a focus on pudendal neuromodulation. The mechanism of action for pudendal nerve stimulation and technique for pudendal neuromodulation will be reviewed. Literature regarding the efficacy of neuromodulation for the treatment of pelvic pain will be summarized. Recent Findings: Multiple studies have demonstrated efficacy of various modalities of neuromodulation in the treatment of chronic pelvic pain. Summary: Neuromodulation may be an effective treatment option for the treatment of chronic pelvic pain, with studies showing a reduction of pain and an improvement in quality of life with various neuromodulation modalities. However, the quality of these studies is generally poor and further large-scale, randomized controlled trials are required. [ABSTRACT FROM AUTHOR]

Purpose of Review: We review the current literature pertaining to recommendations for selecting appropriate patients and performing a test phase for sacral neuromodulation. Recent Findings: Current literature reveals that this therapy can be successfully offered to patients with mild and severe forms of refractory overactive bladder, wet or dry. It can also be offered to elderly patients and patients with concurrent fecal incontinence, even in the setting of a known history of obstetric anal sphincter injury. Patients with non-obstructive urinary retention should be carefully selected with other etiologies ruled out, and an emphasis on those patients with suspected Fowler's syndrome. We also summarize the recommendations for ideal lead placement and the advantages/disadvantages of a percutaneous nerve evaluation in the office compared to a staged procedure. Summary: The use of sacral neuromodulation for bladder dysfunction has evolved over the years. Patient selection and testing technique is an important component in optimizing the success of this therapy. [ABSTRACT FROM AUTHOR]

Purpose of Review: In this review, the current literature available about sacral neuromodulation (SNM) in the management of bladder pain syndrome/interstitial cystitis (BPS/IC) will be addressed. Recent Findings: SNM has emerged in recent years as a minimally invasive option of management for refractory BPS/IC patients that otherwise should undergo reconstructive procedures. Although not approved by the FDA for this specific group of patients, the available data show a favourable response in both objective and subjective variables with a long-lasting effect. The implantation rate after the test phase is greater with the insertion of the quadripolar tined lead than with the monopolar percutaneous nerve evaluation. Most complications can be managed with reprogramming. The reintervention rate is still high, although it decreases when excluding surgeries for battery exchange. Summary: Sacral neuromodulation should be considered in the treatment algorithm of patients with BPS/IC, as suggested in international guidelines. It provides symptomatic relief in a significant proportion of patients, being a fully reversible procedure with a very favourable complications' profile. Reintervention or explantation risk factors have not been consistently established. [ABSTRACT FROM AUTHOR]

Purpose of Review: This review outlines current options for women suffering from both stress urinary incontinence (SUI) and underactive bladder (UAB). This is often a challenging patient population; however, many treatment options are available including behavioral, pharmacologic, and surgical. Therapies can be divided into those specifically targeting either the bladder or the bladder outlet. Recent Findings: For patients with SUI and UAB, several clinical trials have helped to formulate current guidelines. Also, a number of novel techniques and therapeutic agents are currently under investigation. Current surgical treatments frequently employed for SUI include mid-urethral slings and urethral bulking agents. In contrast, the current treatments for UAB are limited to either sacral neuromodulation in women with Fowlers syndrome or in the majority, clean intermittent catheterization. Recent studies have investigated the use of adjustable urethral slings and novel modes of neuromodulation with varying degrees of success. Summary: Choosing the best treatment plan for SUI combined with UAB involves a thorough understanding of a patient's preferences and goals. Fortunately, women have many options that can significantly benefit their quality of life. [ABSTRACT FROM AUTHOR]

Purpose of Review: Sacral neuromodulation (SNM) is an effective, minimally invasive treatment for refractory overactive bladder, non-obstructive urinary retention, and fecal incontinence. Although the treatment is 80% successful, optimal outcomes over time are achieved only by applying precise surgical technique. In this review, we will present the surgical technique for optimal SNM documented in the literature, as well as provide tips for ideal placement based on the authors' experience. Recent Findings: The technique of SNM placement has greatly evolved over the last 10 years with the routine use of fluoroscopy as well as the introduction of the curved, tined lead. With these developments, surgeons have begun to pay more attention to motor thresholds needed to achieve anal bellows and toe flexion responses during staged lead implants. By achieving lower motor thresholds, ideally less than 2 mA, patients have a lower risk of future lead revision and may benefit from longer battery life and greater reprogramming options. Summary: Ideal lead placement for SNM includes superior medial entry into the S3 foramen, with a lateral curvature of the distal lead to follow the S3 nerve root. Specific fluoroscopic findings, along with low motor thresholds for anal bellows and toe flexion, confirm ideal lead placement. Surgeons should make every effort to achieve the ideal lead. In patients with inadequate response to therapy, the lead can be checked on x-ray for ideal characteristics, and a revision should be considered if there is room for improvement. [ABSTRACT FROM AUTHOR]

Purpose of Review: Storage and voiding dysfunction are highly prevalent in patients with multiple sclerosis (MS). Many MS patients fail behavioral modifications and oral medications. Neuromodulation in the form of posterior tibial nerve stimulation (PTNS) and sacral neuromodulation (SNM) is a potential treatment for this group of patients. We review contemporary and impactful literature regarding neuromodulation in the MS patient with lower urinary tract dysfunction.Recent Findings: Large-scale randomized trials regarding the use of neuromodulation in the treatment neurogenic lower urinary tract dysfunction are limited. Despite this, several small prospective studies demonstrate durable responses to neuromodulation in the MS patient. Posterior tibial nerve trials reveal improvements in urodynamic parameters, incontinence episodes, post-void residual volumes, and quality of life metrics. Additionally, SNM in the MS patient results in improvements in daytime and nighttime frequency, urgency symptom, and quality of life. Currently, the frequent need for routine spinal MRI scans precludes the use of SNM. Limited research suggests that some MRI use may be safe, but investigation in this area is ongoing.Summary: Tibial and sacral neuromodulation appear safe and offer significant improvements in lower urinary tract symptoms and quality of life in MS patients who have failed oral medications and behavioral modifications. Though randomized controlled trials are limited in this area, neuromodulation offers great promise to this often refractory and complex patient population. Future studies are warranted and necessary to better evaluate the efficacy of these treatment options. [ABSTRACT FROM AUTHOR]

Purpose of Review: This article aims to review sacral and tibial neuromodulation outcomes in elderly patients. Safety and efficacy of these two neuromodulatory treatments for both urinary and fecal indications are addressed.Recent Findings: Recent data assessing sacral neuromodulation (SNM) for refractory overactive bladder and urge urinary incontinence (UUI) demonstrates that older patients have similar outcomes and complication rates when compared to the general population. For both urinary and fecal indications, SNM has been shown to significantly increase quality of life in older patients. Age has additionally not been a factor affecting tibial nerve stimulation outcomes.Summary: Limited data specifically addresses use of tibial and sacral neuromodulation in elderly patients. Available studies suggest that both treatment options are safe and effective in the older population for urinary and fecal indications, although further study is necessary. [ABSTRACT FROM AUTHOR]

Purpose of Review: Overactive bladder (OAB) is highly prevalent with increasing age. Conservative management including lifestyle adaptation, controlled fluid intake, and bladder training are considered first-line therapeutic options. Second-line options are medication such as antimuscarinics or beta-3 adrenergic receptor agonists. Therapy refractory patients should be referred to a specialist for further evaluation.Recent Findings: It currently remains unclear if patients should undergo routine urodynamic investigation (UDI) before offering third-line therapies like sacral neuromodulation (SNM) or intradetrusor injection of onabotulinumtoxinA (IdetInBotA). The aim of this narrative review was to assess if the presence of detrusor overactivity (DO) can predict treatment success of third-line therapies for OAB.Summary: There is only limited evidence available for both IdetInBotA and SNM, but treatment success does not appear to be related to the presence of DO in baseline UDI. Hence, routine UDI is not mandatory in patients with OAB but remains an option when its outcome is likely to change the treatment strategy or to assess the risk of upper urinary tract deterioration. [ABSTRACT FROM AUTHOR]

Purpose of Review: Post-implant management of sacral neuromodulation is crucial in ensuring the success of therapy. Common management dilemmas include various follow-up schedules, circumstances related to pregnancy, and the possible need for magnetic resonance imaging. Moreover, complications such as lack of or declining efficacy over time, painful stimulation, pain at the implantable pulse generator site, and wound complications need to properly be handled.Recent Findings: In this chapter, each of these above-mentioned scenarios is explored, and the literature concerning them is reviewed. Tips regarding dealing with management dilemmas and practical resolutions of complications are discussed.Summary: In this review, we have given a combination of analysis from the literature and practical suggestions based on years of experience in providing SNM therapy. These tips should be helpful in getting the best result after appropriate patient selection and implant technique have been employed. [ABSTRACT FROM AUTHOR]

Purpose of Review: To report on current and emerging trends in the use of third-line therapies for non-neurogenic overactive bladder (OAB).Recent findings: The use of third-line therapies for OAB has been steadily increasing, but it appears that only a small percentage of OAB patients receive them. Recent research has found an increased risk of dementia associated with cumulative use of anticholinergic medications, including OAB antimuscarinic medications. Cost-effective analyses suggest that these third-line therapies may be worth considering prior to medications.Summary: Research and efforts to improve adherence to current OAB guidelines are needed to increase their use by patients with refractory OAB. Whether or not the therapies we presently consider third line should actually be second line for some of our patients remains to be determined. [ABSTRACT FROM AUTHOR]

Purpose of Review: Sacral neuromodulation and intradetrusor onabotulinum toxinA are FDA approved treatment options for overactive bladder (OAB) and considered third-line therapies according to the American Urological Association (AUA) guidelines. Although each therapy has unique associated risks, infection is a common adverse event shared by both. The purpose of this review is to identify risk factors for infection in third-line therapies for OAB. A PUBMED and MEDLINE search was performed for scientific publications on 'sacral neuromodulation,' 'sacral nerve stimulation,' 'onabotulinum toxinA,' 'Botox,' 'percutaneous tibial nerve stimulation (PTNS)' and 'infection,' and 'overactive bladder (OAB)' between the years 2003 and 2016. Articles were screened for reports on adverse events and were included in the review if they contained information on infection. We also limited this review to idiopathic OAB in adults. Recent Findings: A total of 127 articles were identified (61 in the onabotulinum toxinA and 64 in the sacral neuromodulation (SNM) groups, respectively, and two containing combined data). No articles referencing PTNS and infection were identified; thus, PTNS is not reviewed in this manuscript. Twenty-nine articles met criteria and served as the source information for this article. The primary infection associated with sacral neuromodulation is device-related and ranges between 1.7 and 7.8% in patients implanted for OAB. The most common infection in the onabotulinum toxinA group is a urinary tract infection, with rates ranging from 9.5 to 44%, with the vast majority classified as uncomplicated. Potential risk factors for surgical site infection associated with SNM include patients who are immunocompromised, those with diabetes, or those with a higher BMI. Potential risk factors for urinary tract infection (UTI) associated with onabotulinum toxinA include active medication vs. placebo, urinary retention, and the use of clean intermittent catheterization. Summary: Onabotulinum toxinA and SNM are safe and effective third-line therapies for refractory OAB. Onabotulinum toxinA injection is associated with UTIs, and risk factors appear to be the use of active drug vs. placebo, urinary retention, and use of clean intermittent catheterization. In contrast, SNM is associated primarily with surgical site infection. Risk factors identified include diabetes, higher BMI, or immunocompromised status. [ABSTRACT FROM AUTHOR]

Purpose of Review: This article provides a review of the current literature on the applicability of each treatment for OAB, as well as unique clinical scenarios. In addition, the authors provide their own practical insight on how to approach third-line therapies for OAB. Recent Findings: The treatment of overactive bladder (OAB) is increasingly common amongst specialists. OnabotulinumtoxinA and sacral neuromodulation are both highly effective third-line therapies for OAB, but work via very different mechanisms. The differences between the two are associated with potential benefits and complications unique for each. Summary: The OAB clinician must account for several clinical and personal factors in counseling patients on options. [ABSTRACT FROM AUTHOR]

Purpose of Review: Sacral neuromodulation (SNM) is a widely accepted and minimally invasive treatment for several urologic lower urinary tract pathologies and bowel dysfunction. Treatment for pelvic malignancies is associated with significant rates of urinary, sexual, and fecal dysfunction. The authors sought to determine the role SNM should play in the management of voiding and fecal dysfunction in the male and female cancer survivor patient. There is a lack of studies looking at SNM in the cancer survivor population, particularly in the setting of radiation cystitis or proctitis. Regardless, the authors feel there is a role for SNM in this population. Further studies are needed to further delineate this role and the efficacy of SNM in this challenge to treat patient population. Recent Findings: Voiding dysfunction in the cancer survivor population including urinary urgency, frequency, and urge incontinence is very common. Similarly, fecal incontinence occurs not infrequently and is a major source of patient distress. There is great evidence for SNM via InterStim in urinary urgency, urge incontinence, non-obstructive retention, and fecal incontinence. Studies are lacking, however, in the cancer survivor population. They are non-existent in the postradiation patient population. Summary: SNM is a good treatment option for urinary urgency, urge incontinence, non-obstructive urinary retention, and fecal incontinence. More studies are needed in the cancer survivor population, particularly following radiation therapy. Regardless, the authors feel there is a role in the cancer survivor for SNM. [ABSTRACT FROM AUTHOR]

Purpose of Review: Sacral neuromodulation (SNM) is an FDA-approved treatment option for several refractory pelvic floor disorders given its efficacy and safety profile. Over the past several years, numerous papers have been published on SNM's long-term outcomes, emerging new indications, comparisons with other treatment options, and cost effectiveness. Therefore, we aim to review these updates to the SNM literature. Recent Findings: A PUBMED® and MEDLINE® search was performed for scientific publications on 'sacral neuromodulation' and 'sacral nerve stimulation' between 2011 and 2016. Recent evidence has shown that improved objective and subjective outcomes following placement of SNM are sustained over 3-5 years in the treatment of overactive bladder symptoms and fecal incontinence with minimal adverse events. SNM has also had promising results when used in the treatment of chronic pelvic pain, interstitial cystitis/painful bladder syndrome, constipation, and neurogenic bladder although larger, prospective trials with long-term evaluation are needed to truly establish SNM as an effective intervention for these expanding indications. Summary: SNM is a well-tolerated intervention for refractory bladder and bowel dysfunction with recent long-term longitudinal studies confirming its efficacy and safety. As we gain further insight into SNM's mechanism of action and broader therapeutic indications, we anticipate SNM will become even more widely utilized in the treatment of complex pelvic floor disorders. [ABSTRACT FROM AUTHOR]

This article reviews the current literature in regard to sacral neuromodulation (SNM) for neurogenic lower urinary tract dysfunction (NLUTD). Studies were identified by electronic search of PubMed database (last search in March 2016) and by screening of reference lists. Most case series have several limitations, including lack of standardized criteria for indications, definition of test phase success, criteria for successful clinical outcomes, and short-term follow-up. Of particular interest is the fact that few series used urodynamics to evaluate the effect of SNM in their patients and not all of them were able to demonstrate significant changes even for patients with clinical improvement. SNM seems to be a promising therapy for the treatment of refractory NLUTD in selected patients, with low reported rates of complications. Further prospective studies with larger sample sizes, appropriate disease classification, standardized definitions of success, and longer follow-up with special attention to failure and complication rates are needed to help define the indications for SNM in patients with NLUTD. [ABSTRACT FROM AUTHOR]

The extent of neurologic deficit in spinal cord injury (SCI) is dependent on the primary injury, biologic responses to injury, including inflammation, edema, and scar formation, and neural restructuring. During the recovery phase of SCI, which follows a period of spinal shock lasting weeks to up to 2 years, uninhibited spinal reflexes result in detrusor overactivity with dyssynergia of the urethral sphincter, associated with progressive lower urinary tract dysfunction and potentially upper tract deterioration. Minimization of secondary injury following acute SCI and optimization of nerve regeneration may maximize functional recovery and limit end organ dysfunction, including of the lower urinary tract. Early administration of neuromodulation via electrical or electromagnetic stimulation has been shown to limit secondary injury and potentially restore function. Low-frequency electrical stimulation accelerates axonal growth in the peripheral nervous system and may have a similar benefit in the central nervous system. Limited evidence suggests that sacral neuromodulation has the potential to limit or even prevent maladaptive neural restructuring of the lower urinary tract when administered during the spinal shock phase, when the bladder is areflexic. Herein, we review the pathophysiology of voiding dysfunction following acute injury, existing evidence for the benefit of early SNM in SCI, and possible mechanisms of action, including neural regeneration. [ABSTRACT FROM AUTHOR]

Purpose of review: Sacral neuromodulation (SNM) is an approved treatment in adults. Despite multiple publications about its safety and efficacy in children, SNM has yet to be approved by the Food and Drug Administration for use in this population. We aim to review all the published literature on SNM in children. Recent findings: A PUBMED® and MEDLINE® search was performed for scientific publications on 'sacral neuromodulation' and 'sacral nerve stimulation' in pediatric patients. A total of ten unique articles published between 2006 and 2016 were identified. Each of these publications was thoroughly reviewed and the results included in this article. Refractory bowel and bladder dysfunction (BBD) is the primary indication for SNM placement. The S3 nerve root is the most common anatomical location for lead placement and it is most commonly placed in two stages. The first stage is followed by a trial period to assess symptomatic improvement prior to the second stage when the implantable pulse generator is placed. Symptom improvement ranges across studies but generally improvement or resolution is seen in 60-90 % of patients when properly selected. Potential complications include infection, lead breakage or migration, pain at the insertion site, device erosion, and device failure. Such complications are rare and SNM placement is generally accepted as successful and safe. Summary: Sacral neuromodulation is an effective intervention for refractory bowel and bladder dysfunction in the carefully selected child. This technology is not approved for use in children younger than 16 in the United States, but as the body of literature grows, it is feasible that its application in the pediatric population will become more widely accepted. [ABSTRACT FROM AUTHOR]

Interstitial cystitis/bladder pain syndrome (IC/BPS) is a common entity in patients with chronic pelvic pain. The diagnosis and treatment of this complex condition remains a challenge. This can lead to delayed management, which can significantly impair the psychosocial functioning and quality of life of patients. Although it is not yet approved by FDA, neuromodulation can have therapeutic benefit for chronic pain and sexual dysfunction. We aim to review the current literature evaluating the role of therapies involving sacral and pudendal neuromodulation and percutaneous tibial nerve stimulation in management of pelvic pain and sexual dysfunction. [ABSTRACT FROM AUTHOR]

Detrusor overactivity with impaired contractility (DOIC) is a complicated and under-evaluated condition of the lower urinary tract. The definition is vague, the etiology is unclear, and the treatment is challenging. However, the prevalence of the condition has increased with the increase in the elderly population. Elderly patients often have multifactorial causes of their voiding problems. Thus, evaluation and treatment should be designed on an individual basis, considering the patient's physical ability, cognitive function, comorbidities and available supports. The initial approach is to identify and manage the reversible causes. Behavioral modifications and medical treatment can be effective in selected patients. Anticholinergics should be carefully tried with a minimum starting dose, and post-void residuals should be monitored. β3-Adrenergic receptor agonists may be promising as they induce bladder relaxation yet do not block acetylcholine activity during contraction. Αlpha-antagonists can also be effective with or without bladder relaxants. Encouragingly, a study demonstrated the efficacy of combination treatment of anticholinergic drugs and cholinesterase inhibitors in a DOIC model using rats with spinal cord injury. Sacral neuromodulation has proven efficacy in the treatment of refractory overactive bladder and retention. This might be a potential candidate for the treatment of the combined condition of storage and voiding dysfunction. Botulinum toxin can be used in patients with more bothersome and refractory symptoms of detrusor overactivity, rather than voiding symptoms. Patients should be informed of a risk of retention and be willing to do intermittent catheterization. At the moment, there are no treatments for DOIC that are supported by clinical evidence. Further studies are needed to classify patients and to guide treatment plan considering lower urinary tract and beyond lower urinary tract in the elderly with DOIC. [ABSTRACT FROM AUTHOR]

Overactive bladder (OAB) is a clinical diagnosis given to patients presenting with urgency, with or without urgency incontinence usually accompanied by frequency and nocturia. OAB is prevalent and can significantly impair quality of life. Most patients with OAB will improve with conservative measures or pharmacologic management. However, there are currently multiple minimally invasive options for refractory patients. These include intradetrusor injections of botulinum toxin and two forms of neuromodulation: posterior tibial nerve stimulation and sacral neuromodulation. [ABSTRACT FROM AUTHOR]

There are various etiologies to neurogenic lower urinary tract dysfunction (NLUTD). Anticholinergic therapy and intermittent catheterization have been the mainstay in management of these patients. Newer modalities including neuromodulation (not US Food and Drug Administration approved for this Indication) and intravesical botulinum toxin injection continues to advance the care of these patients resulting in improved quality of life. Female patients with NLUTD offer specific challenges in management that the provider must consider to provide the highest quality of care. This article reviews the various options available today as well as several potential therapies that may be available in the future. [ABSTRACT FROM AUTHOR]

Although neuromodulation is well established for the treatment of non-neurogenic lower urinary tract symptoms, recent literature supports its use in the patient having LUTS associated with a neurologic condition. Sacral neuromodulation, in particular, may see new use as a modality to facilitate neurologic remodeling in spinal cord injured patients as well as children. As a therapeutic option, sacral neuromodulation and dorsal genital nerve stimulation may one day become more effective and more efficient utilizing the concept of closed- loop feedback, where electro-neurogram and bladder pressure data are incorporated into stimulation routines. In addition, some older therapies are reviewed that have recently demonstrated success in this patient population. [ABSTRACT FROM AUTHOR]

The US Food and Drug Administration approved sacral neuromodulation (SNM) in 1997 as a treatment option for patients with urge incontinence and in 1999 for urgency/frequency and nonobstructive urinary retention. SNM uses direct, continuous stimulation of the third sacral nerves through implantation of a pulse generator and electrode. Off-label use of neuromodulation has been used successfully in patients with interstitial cystitis/painful bladder syndrome. This review attempts to provide an update on SNM as an off-label management option for adults with interstitial cystitis based on the available clinical evidence concerning its efficacy. [ABSTRACT FROM AUTHOR]

Neurogenic bladder encompasses many conditions that affect the bladder in patients with neurologic disease. Although there is no standard definition for neurogenic bladder, for the intent and purpose of this review, it is defined as any pathologic process affecting the central and/or peripheral nervous systems that results in urine storage or emptying dysfunction. It often presents clinically as varying degrees of urinary incontinence and/or retention but can present with urinary tract infections, urinary tract stones, or upper urinary tract deterioration. It is up to the clinician to identify wherein the problem lies-is it an outlet problem, bladder problem, or both? What is affected: storage, emptying, or both? These factors should be considered together to identify patients who may benefit from surgical intervention. This review focuses on patient evaluation and surgical interventions for adult patients with neurogenic bladder. Surgical interventions for problems with emptying due to detrusor external sphincter dyssynergia include surgical external sphincterotomy, chemical external sphincterotomy, urethral stent, and sphincter dilation. For detrusor underactivity, detrusor myoplasty and neuromodulation are discussed. For neurogenic detrusor overactivity and impaired compliance and capacity, botulinum toxin injection, sacral neuromodulation, and patch enterocystoplasty are discussed. For decreased compliance/capacity, detrusorotomy is also discussed. For combined problems, urinary diversions are also discussed. [ABSTRACT FROM AUTHOR]

Overactive bladder is a significant health problem for individuals of all ages. Posterior tibial nerve stimulation for overactive bladder is not a new concept, but providers and some third party payers have been slow to embrace it. Until recently, lack of level 1 evidence had raised questions as to its efficacy and duration of benefit. Level 1 evidence now exists to support its use for the treatment of overactive bladder. However, questions remain as to the durability of the benefit. It is likely that chronic maintenance therapy will be necessary in most cases. Emerging evidence may expand the indications for posterior tibial nerve stimulation to include multiple sclerosis, Parkinson's disease, childhood voiding dysfunction, fecal incontinence, interstitial cystitis, and chronic prostatitis. New methods for stimulating this nerve without needles may someday replace current techniques. [ABSTRACT FROM AUTHOR]

Overactive bladder (OAB) remains a remarkably common urologic condition resulting in significant clinical and economic sequelae. Although likely underestimated, the overall prevalence of overactive bladder is projected to be between 15% and 38%. The mainstay of therapy for decades has revolved around anticholinergic pharmaceuticals. However, recent advances in bladder and urothelial physiology have dramatically expanded the treatment options available for OAB management. Herein we present an overview of several emerging options for OAB therapy and review the available literature regarding these therapies. Despite substantial investment into OAB treatment, we are witness to but the genesis of research on detrusor function and urothelial biology that will guide practitioner interventions in the coming decades. Immense opportunity exists for future evaluation of OAB pathophysiology to advance our knowledge regarding management of this multifactorial urologic disorder. [ABSTRACT FROM AUTHOR]

From the time that it was granted US Food and Drug Administration approval, neuromodulation has secured a firm position in the treatment algorithm for overactive bladder. With neuromodulation, physicians were able to bridge the gap between the two ends of the treatment spectrum (medical therapy and open surgery). Sacral nerve stimulation has been the most widely used form of neuromodulation. Recent modifications to its design, namely the development of the tined lead and the launching of the refined InterStim II (Medtronic, Minneapolis, MN), have made sacral nerve simulation even less invasive and more effective. While InterStim is maintaining a level of success with these advancements, peripheral means of neuromodulation are being explored. The current literature takes a closer look at posterior tibial and pudendal nerve stimulation as alternatives to sacral nerve stimulation. The field of neuromodulation is also expanding in terms of the target patient population, as it is being used to treat children, patients with neurological disease, and others. As the role of neuromodulation increases, we must continue to assess its efficacy, safety, and cost-effectiveness in comparison to other therapeutic options. [ABSTRACT FROM AUTHOR]

Fowler’s syndrome—chronic urinary retention and impaired bladder filling sensation without the presence of neurological disease—is a common cause of urinary retention in young women that responds well to treatment with sacral neuromodulation. The mechanisms of disease and therapy have remained difficult to understand, but two recent brain imaging studies—reviewed in this article—have helped dispel the obscurity. Despite different methodology, the two studies concur that brain responses to bladder filling are abnormal and are partially normalized after treatment, with restoration of voiding ability and sensation. The abnormal responses suggest exaggerated pro-continence behavior due to excessive afferent signals from an overactive urethra that inhibit bladder afferent signals at the sacral level. Sacral neuromodulation partially and artificially restores the bladder afferents but does not reverse the underlying sphincter overactivity. [ABSTRACT FROM AUTHOR]

Sacral neuromodulation has had a tremendous impact on the treatment of urinary incontinence and lower urinary tract symptoms for patients with neurologic conditions. This stimulation does not use real-time data from the body or input from the patient. Incorporating this is the goal of those pursuing a neuroprosthesis to enhance bladder function for these patients. Investigators have demonstrated the effectiveness of conditional (also called closed-loop) feedback in animal models as well as limited human studies. Dorsal genital nerve, pudendal nerve, S3 afferent nerve roots, S1 and S2 ganglia have all been used as targets for stimulation. Most of these have also been used as sources of afferent nerve information using sophisticated nerve electrode arrays and filtering algorithms to detect significant bladder events and even to estimate the fullness of the bladder. There are problems with afferent nerve sensing, however. Some of these include sensor migration and low signal to noise ratios. Implantable pressure sensors have also been investigated that have their own unique challenges, such as erosion and sensor drift. As technology improves, an intelligent neuroprosthesis with the ability to sense significant bladder events and stimulate as needed will evolve.