A pioneering procedure to treat severe intractable urinary incontinence at Apollo Hyderguda

Apollo, Hyderguda, Urologist Dr Sanjay Sinha performs a pioneering procedure to treat severe, intractable urinary incontinence in an elderly woman!

Hyderabad, 5thNovember 2015:A 65year old women suffering from severe, intractable urinary incontinence and not amenable to traditional treatment procedures, was successfully treated using a unique and pioneering procedure – Sacral Neuromodulation Therapyat Apollo Hospitals, Hydergudaby Dr Sanjay Sinha, Consultant Urologist, Apollo Hospitals, Hyderguda. This is only thesecond instance in India whenSacral Neuromodulation Therapywas performed.

The patient Mrs KA has been enduring severe urinary incontinence for several years, impacting her quality of life and the embarrassment due to the stench of urine leakage making her homebound. She has been wearing diapers for over two years. She was evaluated at several centers and the treatments proved futile. She presented herself at Apollo Hospital, Hyderguda,a year ago and was diagnosed of Overactive bladder (OAB). She underwent injection of a bladder medicine, which works for most such patients but Mrs KA failed this specialized treatment too. This impacted her further and she was emotionally withdrawn and socially isolated.

Urinary Incontinence can be due to three common causes, Stress urinary incontinencewhere leakage happens on straining or coughing; Urge urinary incontinence due to uncontrolled bladder contractions,which is also called overactive bladder (wet). In contrast, some patients may have urgency without actually leaking andthis is called overactive bladder (dry).Overflow incontinence, is the condition in which the bladder is not emptying properly and ‘overflows’ in an uncontrolled manner.Any of the above can be bothersome but typically urge incontinence patients (overactive bladder) are distressed the most.The reasons for OAB is not very well understood but there seems to be an abnormality of the lining of the bladder (the epithelium) with abnormal signaling upwards to the brain via the spinal cord. Urinary incontinence can impact any age group and in some settings even children suffer. About 15% of the population has some degree of overactive bladder (difficulty in controlling urine), however itis more common in the elderly. While both men and women may suffer, women are more likely have OAB wet form.

OAB has tremendous impact on quality of life, as leakage can cause severe embarrassment and even psychological problems. Elderly patients with OAB are more likely to suffer falls and fractures and a fracture of the spine or hip can often set in motion a chain of events that lead to mortality. In addition, there are some situations where such bladder problems can cause kidney damage, as bladder pressures are critical to the health of kidney. High storage pressures can cause swelling of the kidneys and their damage.

Traditionally OAB has been treated through life style modifications, reduction in fluid, beverages and alcohol consumption. In some instances pelvic exercises can help, as can stopping smoking. Also OAB can be treated by medication, by injecting Botox into the bladder or through Neuromodulation involving nerve stimulation or Bladder surgery.

Mrs KA underwent the first 3 lines of treatment unsuccessfully. However herhusband, a retired pensioner, persisted with his pursuit to seek a remedy. Recently, a new form of treatment for severe and recalcitrant urinary tract disorders, called Sacral Neuromodulationbecame available and the couple was keen to try this specialized treatment.

Sacral neuromodulation consists of placement of an electrode into the sacral spinal nerve root (called S3 nerve root) by a minimally invasive technique. This is then stimulated by a battery device not unlike a cardiac pacemaker. The device was implanted on a trial basis on 23rd September on a day care basis and she went home the same day. Two days later when she walked into the outpatient there was a dramatic change in her. An elated Mrs KA smiling happily asked whether she could throw away all the diapers. A month later the final device implantation was completed and she continues to do well.

Neuromodulation currently has the longest lasting efficacy and the implant typically lasts upwards of 5 years after which it may need replacement, if the patient continues to have severe symptoms. The side effects from Neuromodulation are usually minor and tolerable.

The treatment needs a fluoroscopic imaging in the Operating Room (Called C-arm) and the urologist needs to be trained in the use of the device. The lead in the spinal cord must be placed with precision and this is repeatedly confirmed during the procedure. After initial stage I implantation, the patient tries out the system with an external battery device for a few days. Once it’s confirmed that the response is good, the permanent battery is placed.