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Aktuelle Urol 2001; 32(5): 245-251
DOI: 10.1055/s-2001-17268
Übersicht
Georg Thieme Verlag Stuttgart · New York

Neuromodulation des unteren Harntraktes durch periphere Elektrostimulation somatischer Afferenzen

Neuromodulation of the Lower Urinary Tract by Peripheral Electrical Stimulation of Somatic AfferentsA.  Reitz, B.  Schurch
  • Paracare, Universitätsklinik Balgrist, Zürich
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Publication History

Publication Date:
18 September 2001 (online)

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Zusammenfassung

Fragestellung: Die Neuromodulation der Blasenfunktion durch die periphere Stimulation somatischer Afferenzen soll dargestellt und der Stellenwert dieser Therapie bei Patienten mit funktionellen und neurogenen Blasenfunktionsstörungen diskutiert werden.

Material und Methodik: In dieser Übersichtsarbeit erfolgen die Darstellung und Diskussion der Literatur über die Elektrostimulation somatischer Afferenzen zur peripheren Neuromodulation der Blasenfunktion und deren Bedeutung bei funktionellen und neurogenen Störungen des unteren Harntraktes.

Ergebnisse: Sowohl Tierversuche als auch klinische Studien haben gezeigt, dass durch eine Stimulation genitaler, analer und tibialer Afferenzen eine Modulation der Blasenfunktion möglich ist, und dass Patienten mit funktionellen und neurogenen Blasenfunktionsstörungen von der Behandlung profitieren.

Der genaue Wirkungsmechanismus der Neuromodulation bleibt trotz einiger tierexperimentell untermauerter Hypothesen unklar. In der Mehrzahl der Studien wird der Behandlungserfolg an der Verbesserung der klinischen Symptomatik gemessen, aber auch eine Reihe urodynamisch kontrollierter Untersuchungen konnte einen Benefit für Patienten mit Urge- bzw. Reflexinkontinenz nachweisen. Im Gegensatz zu anderen konservativen und auch chirurgischen Therapieoptionen hat die Behandlung einen potenziell heilenden Ansatz. Bisher wurden keinerlei Nebenwirkungen beobachtet. Wenig bekannt ist über die Langzeitwirkungen, ebensowenig sind kontrollierte Studien verfügbar. Es fehlt weiterhin eine Standardisierung der Stimulationsparameter und der Auswahl- und Erfolgskriterien.

Schlussfolgerung: Die Neuromodulation der Blasenfunktion durch periphere Elektrostimulation somatischer Afferenzen scheint eine effektive Behandlung einer Vielzahl von Funktionsstörungen des unteren Harntraktes zu sein und kann eine neue therapeutische Perspektive zwischen einer ausgereizten medikamentösen Behandlung und invasiveren Strategien eröffnen.

Abstract

Purpose: Neuromodulation by electrical stimulation of peripheral nerves for treatment of lower urinary tract dysfunctions is presented for discussion concerning its importance for patients with neurogenic and non-neurogenic bladder dysfunctions.

Materials and methods: This paper reviews the international literature on the subject and discusses the importance of peripheral neuromodulation for treatment of lower urinary tract dysfunctions.

Results: Animal and clinical trials showed beneficial effects on bladder function by stimulation of genital, anal and tibial afferents in patients with neurogenic and non-neurogenic bladder dysfunctions. However, the exact mode of action of this therapeutical option remains unclear. Mainly clinical symptoms were used to determine success of treatment. Additionally, some urodynamically controlled studies showed benefit for patients with urge or reflex incontinence. Generally no side effects occur. Neuromodulation offers a potential curative effect, even if little is known about long-term effectivness and no controlled clinical trials are available. At present there is still a lack of standardisation in stimulation parameters, patient selection and success criteria.

Conclusions: Neuromodulation of bladder dysfunction by stimulation of somatic afferents appears to be an effective treatment modality for a variety of bladder dysfunctions and offers new perspectives between ineffective drug treatment and surgery.

Key words:

Urinary tract - Electrical stimulation - Afferent pathways

Literatur

  • 1 Morrison J FB. Reflex control of the lower urinary tract. In: Torrens M, Morrison JFB (Hrsg.). The physiology of the lower urinary tract Heidelberg: Springer 1987: 193-235
    Google Scholar
  • 2 Thor K, Kawatani M, De Groat W C. Plasticity in the reflex pathways to the lower urinary tract of the cat during postnatal development and following spinal cord injury.  In: Goldberger M, Gorio A, Murray M (Hrsg.). Development and plasticity of the mammalian spinal cord  Fidia Research Series. 1986;  3 65-81
    PubMedGoogle Scholar
  • 3 Barrington F JF. The component reflexes of micturition in the cat. Parts I and II.  Brain. 1931;  54 177-188
    PubMedGoogle Scholar
  • 4 Kuru M. Nervous control of micturition.  Physiol Rev. 1965;  45 425-494
    PubMedGoogle Scholar
  • 5 Fall M, Erlandson B E, Carlsson C A, Sundin T. Effects of electrical intravaginal stimulation on bladder volume: an experimental and clinical study.  Urol Int. 1978;  33 440-442
    PubMedGoogle Scholar
  • 6 Lindström S, Fall M, Carlsson C A, Erlandson B E. The neurophysiological basis of bladder inhibition in response to intravaginal electrical stimulation.  J Urol. 1983;  129 405-410
    PubMedGoogle Scholar
  • 7 Lindström S, Fall M, Carlsson C A, Erlandson B E. Rhythmic activity in pelvic efferents to the bladder: an experimental study in the cat with reference to the clinical condition „unstable bladder”.  Urol Int. 1984;  39 272-279
    PubMedGoogle Scholar
  • 8 Vodusek D, Light J K, Libby J M. Detrusor inhibition induced by stimulation of pudendal nerve afferents.  Neurourol Urodyn. 1986;  5 381
    PubMedGoogle Scholar
  • 9 De Groat W C. Central nervous system control of micturation. In: O'Donnell P (ed). Urinary incontinence St. Louis: Mosby 33-47
    Google Scholar
  • 10 Craggs M, McFarlane J. Neuromodulation of the lower urinary tract.  Exp Phys. 1999;  84 149-160
    PubMedGoogle Scholar
  • 11 Melzack R, Wall P. Pain mechanism: a new theory.  Science. 1965;  150 971-979
    CrossrefPubMedGoogle Scholar
  • 12 Teague C T, Merrill D C. Electric pelvic floor stimulation. Mechanismus of action.  Invest Urol. 1977;  15 65
    PubMedGoogle Scholar
  • 13 Janez J, Plevnik S, Korosec L, Stanovnic L, Vrtacnik P. Changes in detrusor receptor activity after electric pelvic floor stimulation. Proceedings of International Continence Society, XIth Meeting, Lund. 1981: 22
    Google Scholar
  • 14 Ishigooka M, Hashimoto T, Hayami S, Sasagawa I, Nakada T. Reduction in norephinephine content of urinary bladder by alpha-2 adrenergic antagonists after electric pelvic floor stimulation.  J Urol. 1994;  151 774-775
    PubMedGoogle Scholar
  • 15 Ridge R, Betz W J. The effect of selective, chronic stimulation on motor unit size in developing rat muscle.  J Neurosci. 1984;  4 2614-2620
    PubMedGoogle Scholar
  • 16 Jiang C H. Modulation of the micturition reflex pathway by intravesical electrical stimulation - an experimental study in the rat.  Neurourol Urodyn. 1998;  17 543-553
    CrossrefPubMedGoogle Scholar
  • 17 Jiang C H, Lindström S. Prolonged enhancement of the micturition reflex in the cat by repetitive stimulation of bladder afferents.  J Phys. 1999;  517.2 599-605
    PubMedGoogle Scholar
  • 18 Lindström S, Jiang C H. Repeat periods of electricial stimulation prolong the modulation of the micturition reflex.  Neurourol Urodyn. 2000;  19 542-543
    PubMedGoogle Scholar
  • 19 Nakamura M, Sakurai T. Bladder inhibition by penile electrical stimulation.  B J Urol. 1984;  56 413-415
    PubMedGoogle Scholar
  • 20 Wheeler J S, Walter J S, Zaszczurynski P J. Bladder inhibition by penile nerve stimulation in spinal cord injury patients.  J Urol. 1992;  147 100-103
    PubMedGoogle Scholar
  • 21 Madersbacher H, Kiss G, Mair D. Transcutaneus electrical stimulation of the pudendal nerve for treatment of detrusor overactivity.  Neurourol Urodyn. 1995;  14 501-502
    PubMedGoogle Scholar
  • 22 Kirkham A, Knight S, Casey A, Shan P J, Avenell S, Khastgir J, Craggs M. Conditional neuromodulation of end-fill hyperreflexia to increase bladder capacity in spinal injured patients.  Neurourol Urodyn. 2000;  19 515-516
    PubMedGoogle Scholar
  • 23 Oliver S, Knight S, Susser J, Fowler C, Mundy A, Craggs M. Can conditional Neuromodulation be used to treat urge incontinence.  Eur Urol. 2000;  37 (suppl 2) 32
    PubMedGoogle Scholar
  • 24 Vereecken R L, Das J, Grisar P. Electrical spinkter stimulation in the treatment of detrusor hyperreflexia in paraplegics.  Neurourol Urodyn. 1984;  3 145-154
    PubMedGoogle Scholar
  • 25 Lindstrom S, Fall M, Carlsson C A, Erlandson B E. Rhythmic activity in pelvic efferents to the bladder. An experimental study in the cat with reference to the clinical condition “Unstable bladder”.  Urol int. 1984;  39 272-279
    PubMedGoogle Scholar
  • 26 Erlandson B E, Fall M, Carlson C A. The effect of intravaginal electrical stimulation on the feline urethra and urinary bladder. Electrical parameters.  Scand J Urol Nephrol. 1978;  44 (suppl.) part 1
    PubMedGoogle Scholar
  • 27 Ohlsson B L, Fall M, Frankenberg-Sommar S. Effects of external and direct pudendal nerve maximal electrical stimulation in the treatment of the uninhibited overactive bladder.  British Journal of Urology. 1989;  64 374-380
    PubMedGoogle Scholar
  • 28 Plevink S, Janez J, Vrtacik P, Trsinar B, Vodusek B. Short-term electrical stimulation. Home treatment for urinary incontinence.  World J Urol. 1986;  4 24-26
    CrossrefPubMedGoogle Scholar
  • 29 Khastgir J, Knight S, Shah J, Avenell S, Kirkham A, Craggs M. Effects of neuromodulation by dorsal penil nerve electrical stimulation on detrusor-sphinkter dyssynergia.  Eur Urol. 2000;  37 (suppl. 2) 31
    CrossrefPubMedGoogle Scholar
  • 30 Saha N, Edhem I, Knight S L, Craggs M D. Acute suppression of detrusor hyperreflexia with detrusor-sphinkter-dyssynergia by electrical stimulation of the dorsal penile nerves in patients with a spinal injury.  Eur Urol. 1998;  33 (suppl. 1) 60
    PubMedGoogle Scholar
  • 31 Caldwell K PS, Cook P J, Flack F C. et al . Stress incontinence in femals. Report on 31 cases treated by electrical implant.  J Obstet Gynaecol Br Commonw. 1968;  75 770-780
    PubMedGoogle Scholar
  • 32 Godec C, Cass A S, Ayala G F. Bladder inhibition with functional electrical stimulation.  Urology. 1975;  6 663-666
    CrossrefPubMedGoogle Scholar
  • 33 Fall M. Advantages and pitfalls of functional electrical stimulation.  Act Obstet Gyn Scan. 1998;  168 16-21
    PubMedGoogle Scholar
  • 34 Eriksen B C, Bergmann S, Eik-Nes S H. Maximal electrostimulation of the pelvic floor in female idiopathic detrusor instability and urge incontinence.  Neurourol Urodyn. 1989;  8 219-230
    PubMedGoogle Scholar
  • 35 Plevink S, Janez J. Maximal electrical stimulation for urinary incontinence. Report on 98 cases.  Urology. 1979;  14 638-645
    CrossrefPubMedGoogle Scholar
  • 36 Nakamura M, Tsutomu S, Yukio T, Yasuharu T. Bladder inhibition by electrical stimulation of the perianal skin.  Urol int. 1986;  41 62-63
    PubMedGoogle Scholar
  • 37 Hasan W A, Robson S T, Pridie A K, Neal D E. Transcutaneous electrical nerve stimulation and temporary S3 neuromodulation in idiopathic detrusor instability.  J Urol. 1996;  155 2005-2011
    PubMedGoogle Scholar
  • 38 Walsh I, Loughridge G, Keane P, Johnston R. The effect of TENS on bladder filling activity.  Eur Urol. 1998;  33 (suppl.) 61
    PubMedGoogle Scholar
  • 39 Madersbacher H. Konservative Therapie der neurogenen Blasendysfunktion.  Urologe [A]. 1999;  38 24-29
    PubMedGoogle Scholar
  • 40 Primus G, Kramer G. Maximal external electrical stimulation for treatment of neurogenic or non-neurogenic urgency and/or incontinence.  Neurourol Urodyn. 1996;  15 187-194
    CrossrefPubMedGoogle Scholar
  • 41 Abel I, Ottesen B, Fischer-Rasmussen W, Lose G. Maximal electrical stimulation of the pelvic floor in the treatment of urge incontinence: A placebo-controlled study.  Neurourol Urodyn. 1996;  15 283-284
    PubMedGoogle Scholar
  • 42 Geirsson G, Fall M. Maximal functional stimulation in routine practice.  Neurourol Urodyn. 1997;  16 559-565
    CrossrefPubMedGoogle Scholar
  • 43 Dalmose A L, Rijkhoff N JM, Jorgensen T M, Djurhuus J C. Event driven electrical stimulation of the dorsal penile/clitoral nerve reduces bladder contraction pressure and increases bladder compliance in SCI patients.  Neurourol Urodyn. 2000;  19 499-500
    PubMedGoogle Scholar
  • 44 Schmidt R A, Kogan B A, Tanagho E A. Neuroprothese, in the management of incontinence in myelomeningocele patients.  J Urol. 1990;  143 779-782
    PubMedGoogle Scholar
  • 45 McGuire E J, Zhang S C, Horwinski E R, Lytton B. Treatment of motor and sensory detrusor instability by electrical stimulation.  J Urol. 1983;  129 78-79
    PubMedGoogle Scholar
  • 46 Bemelmans B LH. Neuromodulation of the posterior tibial nerve (perSANSTM) for the treatment of lower urinary tract dysfunction.  Eur Urol. 2000;  37 (suppl. 2) 32
    PubMedGoogle Scholar
  • 47 Stoller M L. Afferent nerve stimulation for pelvic floor dysfunction.  Eur Urol. 2000;  37 33
    CrossrefPubMedGoogle Scholar
  • 48 Klingler H C, Pycha A, Schmidbauer J, Marberger M. The use of peripheral neuromodulation for treatment of detrusor overactivity: an urodynamic based study.  Neurorul Urodyn. 2000;  19 530-531
    PubMedGoogle Scholar
  • 49 Zurkirchen M A, Joller-Jemika H, Tenti G, Hauri D, John H. Peripheral afferent nerve stimulation in the treatment of chronic pelvic pain syndrome: a new therapeutic option?.  Eur Urol. 2001;  39 (suppl. 15) 13
    PubMedGoogle Scholar
  • 50 Schmidt R A. Application of neurostimulation in urology.  Neurourol Urodyn. 1988;  7 585-592
    PubMedGoogle Scholar
  • 51 Schmidt R A, Senn E, Tanagho E A. Functional evaluation of sacral nerve root integrity.  Urology. 1990;  35 388-392
    CrossrefPubMedGoogle Scholar
  • 52 Thon W F, Baskin L S, Jonas U, Tanagho E A, Schmidt R A. Neuromodulation of voiding dysfunction and pelvic pain.  World J Urol. 1991;  9 138-141
    PubMedGoogle Scholar
  • 53 Hohenfellner M, Dahms S E, Matzel K, Thüroff J W. Sakrale Neuromodulation der Harnblase.  Urologe [A]. 2000;  39 55-63
    PubMedGoogle Scholar
  • 54 Bemelmans B LH, Mundy A R, Craggs M D. Neuromodulation by implant for treating lower urinary tract symptoms and dysfunction.  Eur Urol. 1999;  36 81-91
    PubMedGoogle Scholar
  • 55 Hohenfellner M, Schultz-Lampel D, Dahms S E, Matzel K, Thüroff J W. Bilateral chronic sacral neuromodulation for treatment for lower urinary tract dysfunction.  J Urol. 1998;  160 821-824
    PubMedGoogle Scholar
  • 56 Bosch R, Groen J. Neuromodulation: urodynamic effects of sacral (S3) spinal nerve stimulation in patients with detrusor instability or detrusor hyperreflexia.  Behav Brain Res. 1998;  92 141-150
    CrossrefPubMedGoogle Scholar
  • 57 Janknegt R, Van Kerrebroeck P, Nijeholt A A. et al . Sacral nerve modulation for urge incontinence: a multinational, multicenter, randomized study.  J Urol. 1997;  157 (suppl.) 317
    PubMedGoogle Scholar
  • 58 Schmidt R, Gajewski J, Houssana M, Chancellor M. Management of refractory urge frequency syndroms using an implantable neuroprothesis: a northamerican multicenter study.  J Urol. 1997;  57 (suppl.) 317
    PubMedGoogle Scholar
  • 59 Jonas U, Grünewald V, Group M MS. Sacral electrical nerve stimulation for treatment of severe voiding dysfunction.  Eur Urol. 1999;  35 66
    PubMedGoogle Scholar
  • 60 Koldewijn E L, Rosier P F, Meulemann E J, Koster A M, Debruyne F M, Van Kerrebroeck P E. Predictors of success with neuromodulation in lower urinary tract dysfunction: result of trial stimulation in 100 patients.  J Urol. 1994;  152 2071-2075
    PubMedGoogle Scholar
  • 61 Dijkema H E, Weil E H, Mijs P T, Janknegt R A. Neuromodulation of sacral nerves for incontinence and voiding dysfunction. Clinical results and complications.  Eur Urol. 1993;  24 72-76
    PubMedGoogle Scholar
  • 62 Grünewald V, Höfner K, Kuczyk M, Jonas U. Sacral neuromodulation: long-term results of 55 patients with incontinence and voiding dysfunction.  Eur Urol. 1999;  35 16
    PubMedGoogle Scholar
  • 63 Leitlinien urologischer Betreuung Querschnittsgelähmter.  Urologe [A]. 1998;  37 221-228
    PubMedGoogle Scholar

Dr. A. Reitz

Paracare
Universitätsklinik Balgrist

Forchstr. 340

8008 Zürich

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