(From the July 2015 Issue of PediatricsOnline)
Patients with bowel and bladder dysfunction represent a complex and chronic population. When traditional therapies and medications have not been successful in improving symptoms, sacral nerve stimulation (SNS) may be the answer.
In a recent study in the Journal of Pediatric Surgery, researchers at Nationwide Children’s Hospital show that sacral nerve stimulation is improving patient-reported symptoms and quality of life across the board. And patients with bladder and bowel incontinence are benefiting the most.
“While sacral nerve stimulation is not a cure, it can decrease the number of accidents and improve quality of life,” says Seth Alpert, MD, pediatric urologist, a member of the Surgeon Team at the Center for Colorectal and Pelvic Reconstruction at Nationwide Children’s Hospital and senior author on the paper. “Our study demonstrated clinical improvement in most children, reflected by a decrease in the number of interventions needed.”
The study reports that four patients who were previously dependent on bowel flushes for fecal continence were no longer using their cecostomy and were awaiting spontaneous or surgical closure at the time of write-up. Three other patients were able to reduce the number of cecostomy flushes from daily to two or three times a week. All patients experienced significant benefits in terms of decreased symptoms and/or improved quality of life.
The study looked at longitudinal data from the SNS Patient Registry — a prospective database — for 29 patients with SNS with a median age of 12 years. Nearly all (93 percent) had gastrointestinal complaints, while 66 percent had urinary symptoms. Fifty nine percent of patients in the cohort reported both GI and urinary symptoms.
Only a handful of longitudinal studies on SNS in pediatric patients have been done, as the device is still gaining in popularity for treating this population. According to Dr. Alpert, by utilizing the registry to monitor the progress of these patients after the procedure, researchers are able to learn not only about quality of life benefits but also about potential complications.
While SNS placement was well tolerated in most patients, five patients required reoperation due to complications, including infection and discomfort from the battery which required repositioning.
In children, the placement of the device is particularly important. They typically have lower amounts of body fat in which to “hide the device,” which can potentially lead to discomfort in some when the child sits on the floor. To avoid this, Dr. Alpert explains, they adjusted the placement of the device to make it more comfortable during normal childhood activities.
Dr. Alpert and his team plan to continue to track the progress of patients with SNS using the registry.
“We want to learn as much as we can in order to understand who benefits the most so that we can target this treatment toward the highest-yield patients,” says Dr. Alpert, who is also clinical associate professor of Urology at The Ohio State University Wexner Medical Center and director of the Surgical Neuromodulation Center at Nationwide Children's.
Dr. Alpert says that, so far, the patients who have seen the most benefit are those with overactive bladder and urinary incontinence who have failed medical management, non-neurogenic urinary retention, refractory constipation and bowel incontinence.
“Sacral nerve stimulation isn’t indicated for everyone,” Dr. Alpert explains. “We take each patient on a case-by-case basis. They’re considered individually and evaluated by specialists in Urology, Gastroenterology and the Colorectal Clinic to find the best option for that patient. In cases where the bladder and/or bowel dysfunction is refractory to standard treatments, sacral nerve stimulation appears to be helping some of these challenging patients.”
Sulkowski JP, Nacion KM, Deans KJ, Minneci PC, Levitt MA, Mousa HM, Alpert SA, Teich S. Sacral nerve stimulation: a promising therapy for fecal and urinary incontinence and constipation in children. Journal of Pediatric Surgery. 2015 Mar 26. [Epub ahead of print]