Spinelli Michele, Malaguti Silvia, Giardiello Gianluca, Lazzeri Massimo, Tarantola Jessica, Van Den Hombergh Ubi
Unità spinale Unipolare, Azienda Ospedale Niguarda Cà Granda, Milan, Italy.
Neurourol Urodyn. 2005;24(4):305-9. doi: 10.1002/nau.20118.
Pudendal nerve stimulation has beneficial effects on numerous pelvic floor function impairments such as urinary and/or fecal incontinence, retention, and constipation. In preceding literature the implant technique required a fairly complex and invasive surgery, although recent advances with percutaneous placement of the lead through an introducer have made the procedure much less invasive. We performed staged procedure similar to that of sacral neuromodulation (SNM) to place tined lead near the pudendal nerve, using neurophysiological guidance that allowed accurate pudendal nerve stimulation through either perineal or posterior approach. We have named this approach chronic pudendal nerve stimulation (CPNS).
Fifteen neurogenic patients (eight male, seven female) with symptoms of urge incontinence due to neurogenic overactive bladder underwent CPNS. All patients had complete neurophysiological and urodynamic evaluation at baseline and follow-up and were asked to complete voiding and bowel diary for 7 days.
During screening, average number of incontinent episodes per day decreased from 7+/-3.3 to 2.6+/-3.3 (P<0.02, paired t-test). Eight patients became continent, two improved by more than 88% (from 9 to 1 daily incontinence episode) and two patients reduced the number of incontinence episodes by 50%. The implantable pulse generator (IPG) was subsequently implanted in those 12 patients. Three patients without improvement did not continue to second stage. In implanted patients with 6 months follow-up, urodynamic evaluation showed an objective improvement in the maximum cystometric capacity which increased from 153.3+/-49.9 to 331.4+/-110.7 ml (P<0.01, paired t-test). The maximum pressure decreased from 66+/-24.3 to 36.8+/-35.9 cmH2O (P=0.059, paired t-test). Eight patients reported significant improvement in bowel function.
Chronic pundedal nerve stimulation is feasible. Neurophysiological guidance is mandatory to place the lead near the pudendal nerve either using perineal or posterior approach. Further studies must be carried out to identify the best stimulation parameters and to verify the long term results.
阴部神经刺激对多种盆底功能障碍具有有益作用，如尿失禁和/或大便失禁、潴留及便秘。在先前的文献中，植入技术需要相当复杂且具有侵入性的手术，尽管最近通过引导器经皮放置电极的进展使该手术的侵入性大大降低。我们采用了类似于骶神经调节（SNM）的分期手术，在神经生理学引导下，通过会阴或后路将带倒刺电极放置在阴部神经附近，从而实现对阴部神经的精确刺激。我们将这种方法命名为慢性阴部神经刺激（CPNS）。
15例因神经源性膀胱过度活动症出现急迫性尿失禁症状的神经源性患者接受了CPNS。所有患者在基线和随访时均进行了完整的神经生理学和尿动力学评估，并被要求记录7天的排尿和排便日记。
在筛查期间，每天尿失禁发作的平均次数从7±3.3次降至2.6±3.3次（P<0.02，配对t检验）。8例患者实现了控尿，2例改善超过88%（从每天9次尿失禁发作降至1次），2例患者的尿失禁发作次数减少了50%。随后，这12例患者植入了植入式脉冲发生器（IPG）。3例无改善的患者未继续进行第二阶段手术。在植入患者6个月的随访中，尿动力学评估显示最大膀胱测压容量有客观改善，从153.3±49.9毫升增加到331.4±110.7毫升（P<0.01，配对t检验）。最大压力从66±24.3厘米水柱降至36.8±35.9厘米水柱（P=0.059，配对t检验）。8例患者报告肠道功能有显著改善。
慢性阴部神经刺激是可行的。无论是采用会阴还是后路途径，在阴部神经附近放置电极时，神经生理学引导是必不可少的。必须开展进一步研究以确定最佳刺激参数并验证长期效果。
