Sacral Stimulation

One of the major advantages of sacral stimulation is its relatively low side-effect profile compared to other treatment methods, along with its successful outcomes. Studies show that a significant portion of patients undergoing sacral stimulation experience reduced urinary incontinence and regain bladder control. However, this treatment method may not be suitable for every patient; therefore, a detailed evaluation is required before starting the treatment process.

Bladder and Sacral Nerve Anatomy

To ensure the effectiveness of sacral stimulation, it is crucial to understand the anatomy of the bladder and sacral nerves. The bladder and sacral nerves play a critical role in the processes of storing and emptying urine. Understanding the relationships between these anatomical structures aids in a better comprehension of the treatment process.

Structure and Function of the Bladder

The bladder is a muscular organ that stores urine and is part of the urinary system. Urine produced by the kidneys is transported to the bladder via the ureters and stored there. When the bladder fills, it contracts to expel urine through the urethra. A normal bladder has a capacity of approximately 400-600 milliliters, although this capacity may vary from person to person. The main functions of the bladder are:

• Urine storage: The bladder stores urine from the kidneys, preparing it for excretion.
• Urine expulsion: When the bladder is full, signals are sent to the brain via nerves, prompting the need to urinate. The bladder muscles contract, expelling urine through the urethra.

While performing its functions, the bladder requires a complex communication network between the brain and the nervous system. Any disruption in this system or issues with nerve transmission can result in the bladder failing to perform its functions properly.

The Role of Sacral Nerves

Sacral nerves are located in the lower part of the spine and are responsible for controlling the pelvic region. These nerves play a critical role in regulating bladder and bowel functions. Sacral nerves emerge from the S2, S3, and S4 levels of the spinal cord and communicate directly with the bladder. The primary functions of the sacral nerves include:

• Bladder control: Sacral nerves regulate the contraction and relaxation processes of the bladder. They transmit signals from the brain to the bladder to coordinate urination or retention.
• Urine storage: Sacral nerves also regulate the bladder's ability to store urine. They determine when the bladder muscles should relax or contract based on its fullness.
• Pelvic organs: Sacral nerves control bowel functions and some functions of the reproductive organs. The proper functioning of many organs in the pelvic region depends on these nerves.

Sacral nerves are central to the healthy functioning of the bladder. Damage or dysfunction in these nerves can lead to loss of bladder control, resulting in conditions like urinary incontinence or bladder dysfunction. Sacral stimulation aims to address these issues by creating electrical impulses on these nerves, reorganizing disrupted nerve signals, and restoring bladder control.

Bladder Disorders

Various diseases and disorders that affect bladder functions form the basis for sacral stimulation therapy. These disorders can significantly reduce a patient’s quality of life and lead to severe complications if left untreated.

Overactive Bladder (OAB)

Overactive bladder (OAB) is a condition characterized by an uncontrollable need to urinate more frequently than normal due to involuntary bladder contractions. OAB is defined by symptoms such as frequent urination, sudden urgency, and involuntary leakage of urine. While the exact causes of OAB are not fully understood, it is often associated with disrupted communication between the nervous system and the bladder, as well as excessive stimulation of bladder muscles.

• Symptoms of OAB:
  • Needing to urinate more than eight times a day
  • Waking up at night to urinate (nocturnal urination)
  • Sudden urgency and inability to reach the toilet in time, leading to leakage
  • Avoiding social activities and reduced quality of life

OAB is more commonly observed in individuals over the age of 40 and is more prevalent among women. If untreated, this condition can significantly impair quality of life, isolating patients from social activities and leading to psychological issues.

Neurogenic Bladder

Neurogenic bladder is a dysfunction caused by issues in the communication between the bladder and the nervous system. Damage to the brain, spinal cord, or nerve pathways can result in the loss of bladder control. Conditions such as multiple sclerosis, spinal cord injuries, Parkinson's disease, and diabetic neuropathy can lead to neurogenic bladder.

• Types of neurogenic bladder:
  • Hypotonic bladder: A condition where the bladder muscles are weak, causing incomplete emptying of urine.
  • Hyperactive bladder: A condition where the bladder muscles are overly active, leading to frequent urinary incontinence.

Neurogenic bladder can cause complications such as urinary tract infections and kidney damage due to incomplete emptying of urine. Patients may experience symptoms such as urine retention or a sensation of a full bladder without the ability to void. In such cases, sacral stimulation offers an effective treatment option to restore bladder functions.

Applications of Sacral Stimulation

Sacral stimulation (bladder pacemaker) is an effective treatment option for various conditions where bladder control is impaired, including overactive bladder and neurogenic bladder. It works by reorganizing the signal transmission between the nervous system and the bladder, enabling more balanced bladder function. Sacral stimulation is particularly valuable in cases where medication or other conservative treatments are insufficient. Below are detailed explanations of the common applications of this treatment method.

Treatment of Overactive Bladder

Overactive bladder (OAB) is one of the most common bladder disorders and a primary application of sacral stimulation. OAB results from involuntary bladder contractions that occur regardless of whether the bladder is full. Patients experience sudden and intense urges to urinate and, in many cases, cannot reach the bathroom in time, leading to incontinence. Sacral stimulation directly targets the nerves that regulate these contractions, helping to control the bladder's activity.

• Use as an alternative to medication: The first-line treatment for OAB typically involves medications such as anticholinergics or beta-3 agonists. However, these drugs may not always be effective or tolerable due to side effects. Sacral stimulation is used as an alternative or in cases where medication fails. Gentle electrical signals sent to the sacral nerves suppress overactive bladder contractions, reducing the frequency of urination. Studies show that most patients who undergo sacral stimulation experience significant improvement in incontinence symptoms.
• Increase in bladder capacity: One of the benefits of sacral stimulation is its ability to increase bladder capacity. OAB patients often feel the need to urinate before their bladder is completely full. Sacral stimulation helps the bladder hold more urine, reducing the frequency of bathroom visits. This improvement enhances patients' comfort and freedom in daily life.

Treatment of Neurogenic Bladder

Neurogenic bladder is characterized by the loss of bladder control due to damage in the nervous system. Injuries or diseases affecting the brain, spinal cord, or nerve pathways impair the bladder's ability to function normally. Patients may either struggle to empty their bladder (hypotonic bladder) or experience frequent urinary incontinence (hyperactive bladder). Sacral stimulation helps regulate nerve functions in neurogenic bladder patients, restoring bladder control.

• Regulation of nerve connections: Sacral stimulation improves the balance of contraction and relaxation processes in the bladder by reorganizing nerve signals in patients with neurogenic bladder. By stimulating sacral nerves, which have a direct effect on bladder control, the processes of bladder emptying and filling become more manageable. This significantly enhances the quality of life for neurogenic bladder patients.
• Treatment outcomes: Sacral stimulation is typically used in neurogenic bladder patients who have not responded to other treatments, and it has shown high success rates. Patients who lose bladder control due to conditions such as spinal cord injuries or multiple sclerosis can regain bladder function through sacral stimulation. Studies have demonstrated reductions in both urinary incontinence and urine retention, along with significant improvements in bladder function in these patients.

Working Principle of Sacral Stimulation

For sacral stimulation to be successful, it is important to understand how the device works and how it is implanted in the body. The sacral stimulation device controls the nerve signals that regulate bladder functions. The structure, implantation process, and functionality of this device are explained in detail below.

Device Structure and Placement

The sacral stimulation device is a system that permanently implants electrodes to stimulate nerves and regulate bladder function. The main components of the device are as follows:

• Electrodes: Thin wires placed on the sacral nerves. These electrodes deliver electrical stimulation directly to the sacral nerves responsible for bladder control. The electrodes are connected to an external battery unit and are used to transmit electrical signals.
• Battery unit (stimulator): A small device connected to the electrodes, implanted inside the body to send regular electrical signals to the nerves. This battery unit is typically implanted in the hip region and is not visible externally. The battery is designed for long-term use and can function for 3–5 years. Once depleted, it can be replaced with a minor surgical procedure.

Implementation Process

Sacral stimulation therapy typically involves a two-stage process: temporary (test) stimulation and permanent implantation. These steps are essential to evaluate the patient's response to treatment and test the effectiveness of the device.

Temporary Stimulation

The first stage involves temporary stimulation to determine whether sacral stimulation will be effective. In this stage, thin electrodes are placed on the sacral nerves and connected to an external battery unit that can be carried outside the body. The patient lives with this external unit for several weeks to observe whether there is an improvement in bladder control.

• Evaluation of temporary stimulation: During this phase, patients continue their daily lives while observing whether there is an improvement in bladder control. If the patient experiences a noticeable reduction in urinary incontinence during this temporary phase, a permanent stimulator is implanted. This stage is crucial for testing the effectiveness of sacral stimulation without requiring surgery.

Permanent Implantation Process

If the temporary stimulation yields successful results, the second stage involves implanting the permanent sacral stimulation device. This procedure is performed through minor surgery, during which permanent electrodes are placed near the sacral nerves, and the device's battery unit is implanted in the hip or abdominal region.

• Surgical procedure: The implantation is typically performed under local anesthesia. The surgeon makes a small incision to place the electrodes near the sacral nerves and implants the battery unit beneath the skin. The surgery is usually brief, and patients can be discharged on the same day. Recovery takes a few weeks, during which patients should be cautious with physical activities.
• Device adjustments: After implantation, the device is adjusted by a doctor to suit the patient's specific needs. The intensity and frequency of electrical stimulation are personalized for optimal results. Regular adjustments ensure that the patient achieves the best outcome with the device.

Benefits of Sacral Stimulation

Sacral stimulation is a highly effective treatment option for patients with bladder control disorders. It significantly improves patients' quality of life both physically and psychologically. By applying mild electrical stimulation to the sacral nerves, bladder functions are restored, relieving symptoms such as urinary incontinence, urgency, and frequent urination. The main benefits of sacral stimulation are detailed below.

Improvement in Bladder Control

One of the most significant benefits of sacral stimulation is the improvement it provides in bladder control. For conditions such as overactive bladder (OAB) and neurogenic bladder, where patients struggle to control their bladder functions, sacral stimulation helps regulate involuntary bladder contractions and voiding, granting patients better bladder control and improving their quality of life.

• Reduction of overactive bladder symptoms: Symptoms of overactive bladder include frequent urination, sudden urges to urinate, and urinary incontinence. These symptoms can severely limit patients' social lives and daily activities. Sacral stimulation helps alleviate these symptoms by regulating bladder contractions. Studies have shown that approximately 50–80% of patients who undergo sacral stimulation experience a reduction in urinary incontinence and regain bladder control. Particularly in cases where medication is insufficient, sacral stimulation achieves significant success.
• Increase in bladder capacity: Sacral stimulation helps enhance the bladder's ability to store more urine. Patients with overactive bladder often feel the need to urinate frequently, even before their bladder is full. This indicates limited bladder capacity and misinterpreted fullness signals by the nerves. Sacral stimulation increases bladder capacity, helping patients urinate less frequently and reducing the risk of urinary incontinence.
• Regulation of bladder emptying in neurogenic bladder: In neurogenic bladder, patients either struggle to empty their bladder or cannot empty it completely due to nerve damage. This can lead to urine retention and complications such as infections. Sacral stimulation regulates the nerves, facilitating efficient bladder emptying. This helps prevent urine retention and improves bladder function overall.

Improvement in Quality of Life

Another key benefit of sacral stimulation is the significant improvement it brings to patients' quality of life. Bladder dysfunctions not only cause physical challenges but also create psychological and social difficulties. Patients may avoid social environments due to fear of incontinence and experience severe restrictions in their daily activities. By alleviating these symptoms, sacral stimulation greatly enhances patients' quality of life.

• Return to social life: Sacral stimulation eliminates fears of not reaching the restroom on time or urinary incontinence by providing better bladder control. Once patients regain control over their bladder, they can participate in social events, travel, or remain active in their professional lives. This boosts their confidence and allows them to enjoy life more fully.
• Psychological improvement and reduced stress: Bladder dysfunctions can lead to high levels of stress and anxiety in patients. Concerns such as the inability to find a restroom or the panic caused by sudden urges can cause psychological distress. Sacral stimulation eliminates these stressors, allowing patients to lead calmer and more controlled lives. Psychologically relaxed patients can also benefit more from the treatment's effectiveness.
• Freedom of movement: Patients who constantly need to search for restrooms due to fear of incontinence can regain their freedom of movement through sacral stimulation. This is particularly beneficial for individuals who travel or spend long periods in social environments, offering significant relief.
• Improved sleep quality: Patients with overactive bladder often struggle with frequent nighttime urination (nocturia). Sacral stimulation helps address this issue by keeping the bladder under control during the night, thereby improving sleep quality. Better sleep contributes positively to patients' overall health and energy levels.

Side Effects and Risks of Sacral Stimulation

Although sacral stimulation is generally a safe and effective treatment method, there are some potential side effects and risks. Since sacral stimulation involves a surgical procedure, complications such as infection, technical issues with the device, and electrode placement problems may occur. This section examines the potential risks of sacral stimulation and the challenges that may arise after treatment in detail.

Possible Complications

Sacral stimulation carries certain risks due to its surgical nature. These risks can be associated with the surgical procedure itself or the implanted device.

• Risk of infection: After the sacral stimulation device is implanted, there is a risk of infection at the implantation site. This risk increases if proper care is not taken during the postoperative recovery process. Symptoms of infection may include redness, swelling, pain, or fever at the implantation site. In severe cases of infection, the device may need to be removed.
• Device malfunction or loss of function: The sacral stimulation device operates using an implanted battery unit. Although rare, malfunctions or loss of function in the battery unit can occur. If electrical stimulation becomes insufficient or stops entirely, the device may need to be replaced. Additionally, if the electrodes shift out of position or are improperly placed, nerve stimulation may be ineffective. In such cases, surgical intervention may be required to reposition the electrodes.
• Pain or discomfort: Some patients may feel mild discomfort or pain at the implantation site after the sacral stimulation device is placed. This typically diminishes during the recovery process. However, improper placement of the electrodes or pressure exerted by the device under the skin may cause pain. In such cases, the position of the device may need to be adjusted.

Device Adjustment and Maintenance

After the sacral stimulation device is implanted, regular adjustments are necessary to ensure the device functions correctly and optimally regulates bladder functions. Patients must attend regular follow-ups to ensure the device is working properly and to maintain optimal stimulation.

• Programming and adjustments: The sacral stimulation device can be programmed according to the patient's needs. At the start of treatment, the electrical stimulation's intensity and frequency are adjusted by the physician. These settings are tailored to the patient's symptoms to ensure the device operates most effectively. As the treatment progresses, further adjustments may be made based on the device's performance and the patient's response.
• Periodic check-ups: After implantation, regular check-ups are essential to ensure the device is functioning correctly. These evaluations assess issues such as electrode displacement, battery performance, or programming concerns. Regular follow-ups are critical to maintaining the device's effectiveness.
• Battery life and replacement: The battery life of the sacral stimulation device typically ranges from 3 to 5 years. Once the battery reaches the end of its life, it is replaced through a minor surgical procedure. As the battery nears depletion, the device's stimulation may weaken or stop entirely. In such cases, patients should contact their physician to address the issue.

Sacral Stimulation Treatment Process

The sacral stimulation treatment process involves a series of steps, from the proper evaluation of the patient to device implantation. Each step is critical for the success of the treatment. These stages include determining patient eligibility, performing surgery, managing the recovery process, and conducting follow-up evaluations. Each patient's response to treatment may vary, making a personalized approach essential.

Patient Selection and Evaluation

Sacral stimulation therapy may not be suitable for all patients. To ensure the success of the treatment, appropriate patient selection is crucial. During this process, factors such as the patient's overall health, the cause and severity of the bladder problem, previous treatment attempts, and other medical considerations are taken into account. Additionally, a temporary test stimulation phase is used to evaluate how the patient responds to the treatment.

• Who is it suitable for? Sacral stimulation therapy is generally recommended for patients with chronic bladder problems such as overactive bladder (OAB), neurogenic bladder, and urinary incontinence who have not benefited sufficiently from other treatments. It is particularly effective for patients who do not respond to medication or physical therapy. Before treatment, conditions such as urinary tract infections, anatomical abnormalities, or severe psychological disorders are evaluated, as these factors may affect the suitability of the therapy.
• Test stimulation: The first stage of sacral stimulation therapy involves testing the patient with a temporary stimulator. This test stimulation phase is used to observe how the patient responds to the treatment before a permanent device is implanted. During the test phase, temporary electrodes are placed near the nerves through a minor surgical procedure, and stimulation is provided via an external battery unit. This process typically lasts one week, during which improvements in bladder control are monitored. If significant improvements in urinary incontinence, urgency, and other bladder issues are observed, the treatment proceeds with the implantation of the permanent device.
• Evaluation of test stimulation: During the test stimulation phase, patients continue their daily activities while monitoring changes in their bladder control. Physicians assess the effectiveness of stimulation by reviewing the patient's bladder diaries. If the patient responds positively to the test stimulation, a decision is made to proceed with the permanent implantation of the sacral stimulation device.

Surgical Procedure

If the temporary test stimulation is successful, a surgical procedure is performed to permanently implant the sacral stimulation device. This is typically a short and minimally invasive procedure. Patients can undergo this operation under local anesthesia, and in most cases, they can be discharged on the same day. The surgery involves the proper placement of the device, aligning it with the nerves, and implanting the battery unit into the body.

• How is the surgical procedure performed? During the surgery, the surgeon makes a small incision in the lower back to access the sacral nerves. Permanent electrodes are then placed near the nerves and connected to the external battery unit. The battery unit is usually implanted in the hip area and positioned under the skin. During the procedure, various tests are conducted to ensure that the electrodes are correctly positioned. These tests help evaluate how the nerves respond to electrical stimulation and determine the effectiveness of the stimulation.
• Key considerations during surgery: Proper placement of the electrodes is the most critical aspect of the surgical procedure. Due to the sensitive structure of the sacral nerves, the optimal positioning of the electrodes directly impacts the success of the treatment. Misplaced electrodes can render nerve stimulation ineffective or cause excessive stimulation. The surgeon performs test stimulations during the procedure to confirm that the electrodes are correctly connected to the targeted nerves, ensuring their precise placement.
• Post-surgical recovery process: After the sacral stimulation device is implanted, patients go through a recovery period lasting several weeks. During this time, patients should avoid strenuous physical activities and take care of the surgical site. Once the healing process is complete, the device is activated. Throughout this period, patients should maintain regular communication with their physicians and report any complications or discomfort for prompt intervention.

Follow-Up and Adjustments

Post-surgical follow-up and regular device adjustments are crucial for maintaining the success of the treatment. After the sacral stimulation device is implanted, adjustments are made to ensure the device functions correctly and provides lasting symptom improvement. The device's electrical stimulation can be customized to meet the individual needs of the patient.

• Device programming: After implantation, the sacral stimulation device is programmed by the physician to suit the patient's symptoms. The intensity and frequency of the electrical stimulation are tailored to each patient. These adjustments are made to help the patient manage bladder function as effectively as possible. Throughout the treatment process, the programming is regularly reviewed and updated as needed.
• Optimizing adjustments: Device programming is a vital part of the treatment process. Initial adjustments may not be optimal for every patient, so modifications may be necessary during the course of treatment. Patients can inform their physicians of any discomfort or changes in bladder function to request adjustments to the device's settings. Fine-tuning the device ensures that patients achieve the best possible bladder control.
• Long-term follow-up: Sacral stimulation therapy is a long-term treatment, requiring regular follow-up appointments. Patients should visit their physicians periodically to monitor the device's performance and detect any potential complications early. The device's battery life, electrode positioning, and overall functionality should be regularly assessed. When the battery life ends, a planned surgical procedure is scheduled to replace the battery. Additionally, adjustments to the device's settings can be made as needed.

Alternative Treatment Methods to Sacral Stimulation

Although sacral stimulation is an effective treatment method for urinary incontinence and bladder dysfunctions, there are alternative methods available. Some patients may prefer less invasive treatments that do not require surgical intervention. Below are detailed explanations of alternative methods commonly used as substitutes for sacral stimulation therapy.

Medication Therapy

The first-line treatment for conditions such as overactive bladder (OAB) and urinary incontinence is often medication therapy. Medications like anticholinergics and beta-3 adrenergic agonists are used to control bladder muscles and prevent urinary incontinence. However, when medications are ineffective or cannot be tolerated due to side effects, sacral stimulation becomes an alternative option.

• Anticholinergic drugs: These medications are used to control the excessive contractions of bladder muscles. Anticholinergics reduce bladder spasms via the nervous system, thereby lowering urinary frequency and incontinence episodes. However, these drugs may cause side effects such as dry mouth, constipation, and blurred vision. Some patients may discontinue medication therapy due to these side effects.
• Beta-3 adrenergic agonists: These drugs help relax the bladder muscles, allowing the bladder to hold more urine. Beta-3 agonists are considered to have fewer side effects compared to anticholinergics; however, some patients may not respond to this therapy. While medication therapy can be effective for some patients, many report a decrease in the drugs' efficacy over time.

Behavioral Therapies

Other treatment options to sacral stimulation include behavioral therapies, which aim to regulate bladder functions and help patients regain bladder control.

• Bladder training: Bladder training is a therapy method aimed at helping patients regulate their urination habits. This training allows patients to urinate at set intervals, helping maintain control over the bladder. By managing their toilet habits, patients can reduce the risk of urinary incontinence.
• Kegel exercises: Kegel exercises are used to strengthen pelvic floor muscles and improve bladder control. These exercises enhance the strength of muscles directly affecting the bladder and reduce urinary incontinence problems. Regular Kegel exercises enable patients to manage bladder control more effectively. However, this method may be effective only in milder cases and insufficient for advanced bladder issues.

Surgical Interventions

In cases where medication and behavioral therapies are insufficient, certain surgical interventions can be considered as alternatives to sacral stimulation. These surgical procedures aim to control bladder functions or increase bladder capacity.

• Botox injections: Botox injections into the bladder muscles are a treatment method used for overactive bladder cases. Botulinum toxin is injected into the bladder muscles to reduce muscle contraction activity. This treatment is typically temporary, with effects lasting 6-9 months. After the effects of Botox wear off, repeat injections may be required.
• Bladder augmentation surgery: Bladder augmentation surgery (augmentation cystoplasty) is a surgical method used to increase bladder capacity and reduce urinary incontinence issues. During this surgery, additional tissue is added to the bladder to enlarge its capacity. However, this procedure is a major operation, making it riskier and typically reserved as a last resort.

Conclusion

Sacral stimulation (bladder pacemaker) stands out as a long-term and effective treatment option for patients with chronic bladder disorders. Its ability to regulate bladder functions and its low complication rates significantly improve patients' quality of life. Advances in technology have made sacral stimulation an increasingly popular option for addressing bladder control problems. Early diagnosis, proper patient selection, and regular follow-ups play a key role in the success of this treatment. In conclusion, sacral stimulation offers an effective solution for many patients struggling with bladder control issues, and future technological advancements are expected to further enhance its success.