Stop that leak!
Sacral neuromodulation, or a bladder pacemaker, is used to help people with bladder control problems.
EAT, drink, poo and pee ... that’s what most normal people do every few hours.
We all take peeing for granted. When the brain signals, we rush to the loo to relieve ourselves.
For others, these signals can go haywire and peeing becomes a nightmare. They spend more than half their time visiting these not-so-royal thrones.
For patients like Harjeet Kaur, peeing was an annoying affair as she had the urge every 15 minutes. Alas, her urine would only trickle out.
She could never empty her bladder fully and it was constantly distended. She experienced recurring urinary tract infections from urine stagnation.
Doctors wrongly diagnosed her condition as overactive bladder (OAB), but no amount of medication could solve her woes.
“My lifestyle was messed up because I had to go to the washroom so often. When my husband drove over a speed bump, it would cause me to want to go to the washroom. If we attended an event, I’d have to sit close to the toilet. I was always stressed, angry, irritated and emotional,” recalls Harjeet, 52.
Doctors recommended she use a catheter to drain the urine, but the homemaker was too embarrassed. Eventually, Harjeet began avoiding social situations because she didn’t want any “leaky accidents”.
Last year, she was referred to another urologist who told her she was actually suffering from an underactive bladder (UAB) or urinary retention. Possible non-obstructive causes include spinal cord injury, diabetes, previous pelvic surgery, stroke and an ageing bladder.
Harjeet had no idea how the problem came about, although she remembers having some spinal issues years earlier. The specialist suggested she implant a bladder pacemaker.
She says, “I was sceptical at first, but since I had tried everything, I decided to give it a go. I had it implanted earlier this year and it was like a miracle. I no longer have retention problems and am happy to enjoy life once again.”
Electrical stimulation
Many are not aware of a treatment option called sacral neuromodulation, or a bladder pacemaker, which functions similarly to a heart pacemaker.
The sacral neuromodulation system permits electrical stimulation of the sacral nerves via an implantable neuro stimulator device that includes a neuro stimulator and a lead wire.
“We place it inside the bladder, somewhere very close to the nerves, and that will help rhythmise the bladder contractions. Those with UAB are able to pass urine well, and for those with OAB, the gadget will relax the bladder a bit,” explains consultant urologist Dr Warren Lo.
In the human body, the two kidneys are the organs that produce urine, which is drained out via the ureters. The urine accumulates in the bladder before it comes out.
The bladder has to undergo contraction and relaxation of the sphincter muscles before the urine comes out. This mechanism is governed by the spinal cord, which is connected to the brain.
OAB and UAB are two spectrums of bladder dysfunction. An OAB consists of sudden, immediate urges to use the bathroom, and often, involuntary loss of urine or incontinence.
Unlike an OAB, which increases urgency to urinate, an UAB bladder involves prolonged urination with or without the feeling of complete bladder emptying. Hesitancy, a reduced ability to feel the bladder filling, and a slow urine stream, usually accompanies urination.
Patients suffer in silence and tend to
accept these disruptive conditions as part of their lives, which directly impacts their health, lifestyle, and in some cases, may lead to depression.
According to statistics from the Continence Foundation Malaysia, urinary incontinence affects 200 million people worldwide, with one in four women over the age of 18 experiencing episodes of leaking urine involuntarily.
It is also twice as common in women compared to men.
“The commonest cause that leads people to OAB is still caffeinated products like coffee and tea. The treatment for OAB is essentially physiotherapy, lifestyle modification and medication, which normally produces side effects like constipation and dry mouth.
“Without surgery, medication is the way to go, but the literature shows that after a year, only 30% will continue taking medication while the other 70% drop out because they cannot tolerate the side effects.
“For those not responsive to the medication, they go on to have Botox, which paralyses the muscles. So if the bladder is contracting too much, you want to half-paralyse the muscle rather than paralysing it completely.
“But, we have patients who are not suited for Botox due to certain diseases, so they are left with no choice except lifestyle modifications and pelvic floor exercises. However, these often do not work,” says Dr Lo.
Last resort
Sacral neuromodulation is the last resort for patients like retiree Noorkaman Salleh, 55.
Like Harjeet, he suffered from peeing issues after having myasthenia gravis, a chronic autoimmune neuromuscular disease characterised by varying degrees of weakness of the skeletal (voluntary) muscles of the body.
He had to dash to the toilet every 10 minutes. All medical intervention failed to work. Life was miserable until he discovered the bladder pacemaker.
In 2014, he had the procedure done, and after a few months, he noticed a gradual improvement as sprints to the restroom decreased.
Noorkaman says, “It took me a while to adjust, but now, I only go to the toilet once every two or three hours. I’m more comfortable and have learnt to be independent again. I’ve also cut down on a lot of my medication for my neurological problem.”
This smart system canc modulate-accordose ingly.
Dr Lo adds, “For tho who don’t feel the bladder, it enables the e person to regain the sensation back to norm mal to pass urine. The electrical stimulation modulates the nerves not only into the blad der, but also, into the bowel and the pelvic floorf muscles. It also works for people with h faecal incontinence.
“The intensity and frequencyf of the pulses can be modified by bo oth the physician and the patient through an n externalprogramy mer. There is actually a trial period of one to six weeks because we e need to be sure the gadget is going to wor rk.
“During this time, wew plant the gadget inside but leave the wirew sticking out so patients can learn to c change the intensity themselves. Once we f find the patient issuitas ble, we put it inside as a permanent implant. Or else, we take it out .”
To date, more than 20,000 patientsworlded wide have been treate with this therapy for severe bladder voidin ng dysfunction. Periodic follow-up, usually eve ery six to 12 months, is recommended to mon nitor the therapy’s effectiveness.
Sacral neuromodula ation is a niche field in urology, and iss only available at a handful of public and private hospitals locally. The c cut off age is above 16.
“For OAB, it’s the las st resort, but for UAB, it’s the on nly resort, otherwise, it’s a cathet ter for life. This therapy only invo olves a small scar, as it’s not a major surgery. We select pat tients very carefully. All the patie ents (youngd est was 18) have foun relief,” says Dr Lo.