Successful bilateral pudendal neuromodulation to treat male detrusor areflexia following severe pubic symphysis fracture, a case report

Abstract

BackgroundA Drum Dock Manager in an auto manufacturing company suffers a pelvic fracture, severing the bulbar urethra and completely fracturing the right side of his pelvis.He is unable to void without catheterization but has a complete sensation to void. Can neuromodulation help him achieve spontaneous voiding?Case presentationWe reviewed the electronic medical record of Mr. M.E. from Detroit Medical Center following his 2012 forklift accident and subsequent orthopedic surgeries. He successfully underwent bilateral sacral neuromodulation, with a resulting max flow of 16.8 mls/sec and post-void residual urine of 50–100 mls. Unfortunately, he later presented with bilateral pocket and sacral lead infection, and both systems had to be removed. Six weeks later, M.E. had bilateral pudendal neurostimulation placement to avoid the previously infected areas. Max flow improved to 14.5 mls/sec and 0–50 mls residual urine. However, urodynamics proved that his Pdet at max flow was in excess of 120 cm of H20 pressure while he had been on finesteride and tamsulosin for the preceding five years for the management of his documented benign prostate hyperplasia symptoms. He underwent Green light laser transurethral resection of the prostate and had max flow improvement to 22.5 mls/second with zero residual urine with multiple straight catheterization confirmations.ConclusionSacral neuromodulation may successfully correct traumatic urinary retention in male patients. Additionally, pudendal neuromodulation can be successfully utilized as a salvage method for an infected sacral neuromodulation impulse generator (IPG) and tined lead with a return to proper voiding.

Sacral electroacupuncture as a treatment for urge urinary incontinence: a prospective case series

“…As shown in Figure 3, the position of the lower needle tip is similar to where the Bion device or tined lead is implanted for PNM (adjacent to the PN at Alcock’s canal). 20,23,26 In the ischiorectal fossa, the PN branches into the perineal nerve innervating the PFM, the skin of the labium majus and the dorsal nerve of the clitoris (innervating the clitoral shaft skin). 27 Therefore, the needling sensation is only referred to the urethra, and the rhythmic peri-urethral PFM contractions are felt when moderate-intensity electrical stimulation is delivered.…”

Improving clinical outcomes for women with overactive bladder or urinary retention symptoms: a comparison of motor response voltages (1–9 V) during Stage 1 sacral neuromodulation

“…This method may promptly identify the S 3 nerve and may even minimise operative time and the patient's anaesthetic. However, between 2001 and 2015, there was no conjecture that a particular voltage would affect improved patient outcomes during a Stage 1 SNM motor response trial . It is of paramount importance to understand that every Stage 1 SNM is an electromyography (EMG) study in which a specific voltage is applied through a needle to the S 3 nerve to stimulate a motor contractile response.…”

“…Improvements are not limited to software/hardware innovations. An alteration in Stage 1 SNM approach and technique was brought to light during a review of the fundamentals of electrophysiological theory, namely that the lower the amount of voltage used to stimulate a motor response, the higher the potential for improved stimulation of the intended muscle unit . The Medtronic Corporation has never heralded any recommendations about the amount of voltage for a motor response, and this element of adjustment has not been explored in the SNM literature .…”

Bilateral electrical pudendal nerve stimulation as additional therapy for lower urinary tract dysfunction when stage II sacral neuromodulator fails: a case report

“…Because SNM therapy stimulates only some of the afferent fibres of the pudendal nerve, direct neurostimulation of the PN may be more effective [ 14 , 15 ]. Pudendal neurostimulation (PNM) is growing as an alternative surgical option for patients who experience a decrease in the effectiveness of SNM and in those who were never satisfied after an SNM procedure [ 16 , 17 ]. The PNM procedure involves a small implantable neurostimulator device (Bion, Advanced Bionics Corporation, Valencia, CA, USA) placed directly into one side of Alcock’s canal to stimulate the PN [ 15 , 18 ].…”