Skip to main content

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

  • Review Article
  • Published:

Sacral neuromodulation for urinary retention

Nature Clinical Practice Urology volume 5, pages 657–666 (2008)Cite this article

Abstract

Urinary retention without an identifiable urological cause presents a diagnostic and therapeutic challenge. Patients with nonobstructive chronic urinary retention usually have to rely on intermittent self-catheterization or indwelling suprapubic or transurethral catheters, which significantly affect quality of life. For some patients, however, sacral neuromodulation (SNM) offers an effective therapeutic alternative, and women with primary disorder of urethral sphincter relaxation (Fowler's syndrome) seem to respond particularly well to this treatment. Although the mechanism of action of SNM is not well understood and requires further investigation, it seems to involve afferent mediation of spinal cord reflexes and brain networks. The evolution of SNM devices and improvements in surgical and testing techniques, especially the introduction of the two-stage tined lead procedure, have considerably reduced the failure, adverse event and surgical revision rates associated with SNM, ensuring that this modality is an effective minimally invasive treatment for urinary retention.

Key Points

  • In selected patients with chronic urinary retention, sacral neuromodulation (SNM) offers an important therapeutic alternative to intermittent self-catheterization or indwelling suprapubic or transurethral catheters, which significantly affect quality of life

  • SNM might be an effective treatment for restoring voiding function, thereby improving quality of life and reducing voiding-related health-care costs

  • Technical improvements in devices and changes in surgical and testing techniques have considerably reduced failure, adverse event and surgical revision rates, and have made SNM an effective, minimally invasive treatment

  • Although the mechanism of action of SNM is not well understood, it seems to involve modulation of spinal cord reflexes and brain networks by peripheral afferents

This is a preview of subscription content, access via your institution

Access options

Buy this article

  • Purchase on Springer Link
  • Instant access to full article PDF
Buy now

Prices may be subject to local taxes which are calculated during checkout

Figure 1: Placement of a tined lead for sacral neuromodulation.
Figure 2: The test phase.
Figure 3: Permanent implantation.

Similar content being viewed by others

References

  1. Tanagho EA and Schmidt RA (1982) Bladder pacemaker: scientific basis and clinical future. Urology 20: 614–619

    Article  CAS  Google Scholar 

  2. Hassouna MM et al. (2000) Sacral neuromodulation in the treatment of urgency-frequency symptoms: a multicenter study on efficacy and safety. J Urol 163: 1849–1854

    Article  CAS  Google Scholar 

  3. Siegel SW et al. (2000) Long-term results of a multicenter study on sacral nerve stimulation for treatment of urinary urge incontinence, urgency-frequency, and retention. Urology 56: 87–91

    Article  CAS  Google Scholar 

  4. Bosch JL and Groen J (2000) Sacral nerve neuromodulation in the treatment of patients with refractory motor urge incontinence: long-term results of a prospective longitudinal study. J Urol 163: 1219–1222

    Article  CAS  Google Scholar 

  5. Jonas U et al. (2001) Efficacy of sacral nerve stimulation for urinary retention: results 18 months after implantation. J Urol 165: 15–19

    Article  CAS  Google Scholar 

  6. Kessler TM et al. (2007) Sacral neuromodulation for refractory lower urinary tract dysfunction: results of a nationwide registry in Switzerland. Eur Urol 51: 1357–1363

    Article  Google Scholar 

  7. van Kerrebroeck PE et al. (2007) Results of sacral neuromodulation therapy for urinary voiding dysfunction: outcomes of a prospective, worldwide clinical study. J Urol 178: 2029–2034

    Article  Google Scholar 

  8. Takeda M et al. (2003) Diagnosis and treatment of voiding symptoms. Urology 62: 11–19

    Article  Google Scholar 

  9. Fowler CJ et al. (1988) Abnormal electromyographic activity of the urethral sphincter, voiding dysfunction, and polycystic ovaries: a new syndrome? BMJ 297: 1436–1438

    Article  CAS  Google Scholar 

  10. Abrams P et al. (2002) The standardisation of terminology of lower urinary tract function: report from the Standardisation Sub-committee of the International Continence Society. Neurourol Urodyn 21: 167–178

    Article  Google Scholar 

  11. De Ridder D et al. (2007) The presence of Fowler's syndrome predicts successful long-term outcome of sacral nerve stimulation in women with urinary retention. Eur Urol 51: 229–233; discussion 233–234

    Article  Google Scholar 

  12. Spinelli M and Sievert KD (2008) Latest technologic and surgical developments in using InterStim™ therapy for sacral neuromodulation: impact on treatment success and safety. Eur Urol [10.1016/j.eururo.2008.01.076]

  13. Janknegt RA et al. (1997) Improving neuromodulation technique for refractory voiding dysfunctions: two-stage implant. Urology 49: 358–362

    Article  CAS  Google Scholar 

  14. Hohenfellner M et al. (1998) Bilateral chronic sacral neuromodulation for treatment of lower urinary tract dysfunction. J Urol 160: 821–824

    Article  CAS  Google Scholar 

  15. Braun PM et al. (1999) Tailored laminectomy: a new technique for neuromodulator implantation. J Urol 162: 1607–1609

    Article  CAS  Google Scholar 

  16. Spinelli M et al. (2003) New percutaneous technique of sacral nerve stimulation has high initial success rate: preliminary results. Eur Urol 43: 70–74

    Article  Google Scholar 

  17. Spinelli M et al. (2003) New sacral neuromodulation lead for percutaneous implantation using local anesthesia: description and first experience. J Urol 170: 1905–1907

    Article  Google Scholar 

  18. Scheepens WA et al. (2001) Buttock placement of the implantable pulse generator: a new implantation technique for sacral neuromodulation—a multicenter study. Eur Urol 40: 434–438

    Article  CAS  Google Scholar 

  19. Sievert KD et al. (2007) Permanente sakrale Neuromodulation mittels InterStim®: Ergebnisse einer Anwenderbefragung zu aktuellen technischen Entwicklungen. J Urol Urogynäkol 4: 14–16

    Google Scholar 

  20. Swinn MJ et al. (2000) Sacral neuromodulation for women with Fowler's syndrome. Eur Urol 38: 439–443

    Article  CAS  Google Scholar 

  21. Aboseif S et al. (2002) Sacral neuromodulation as an effective treatment for refractory pelvic floor dysfunction. Urology 60: 52–56

    Article  Google Scholar 

  22. Bross S et al. (2003) The role of the carbachol test and concomitant diseases in patients with nonobstructive urinary retention undergoing sacral neuromodulation. World J Urol 20: 346–349

    PubMed  Google Scholar 

  23. Datta SN et al. (2008) Sacral neurostimulation for urinary retention: 10-year experience from one UK centre. BJU Int 101: 192–196

    PubMed  Google Scholar 

  24. Sievert KD et al. (2007) Subcutaneous tunneling of the temporary testing electrode significantly improves the success rate of subchronic sacral nerve modulation (SNM). World J Urol 25: 607–612

    Article  Google Scholar 

  25. Scheepens WA et al. (2002) Long-term efficacy and safety results of the two-stage implantation technique in sacral neuromodulation. BJU Int 90: 840–845

    Article  CAS  Google Scholar 

  26. Malaguti S et al. (2003) Neurophysiological evidence may predict the outcome of sacral neuromodulation. J Urol 170: 2323–2326

    Article  CAS  Google Scholar 

  27. Goh M and Diokno AC (2007) Sacral neuromodulation for nonobstructive urinary retention—is success predictable? J Urol 178: 197–199

    Article  Google Scholar 

  28. Borawski KM et al. (2007) Predicting implantation with a neuromodulator using two different test stimulation techniques: a prospective randomized study in urge incontinent women. Neurourol Urodyn 26: 14–18

    Article  Google Scholar 

  29. Kessler TM et al. (2005) Prolonged sacral neuromodulation testing using permanent leads: a more reliable patient selection method? Eur Urol 47: 660–665

    Article  Google Scholar 

  30. Kessler TM et al. (2008) Safety of prolonged sacral neuromodulation tined lead testing. Curr Med Res Opin 24: 343–347

    Article  Google Scholar 

  31. Everaert K et al. (2004) A prospective randomized trial comparing the 1-stage with the 2-stage implantation of a pulse generator in patients with pelvic floor dysfunction selected for sacral nerve stimulation. Eur Urol 45: 649–654

    Article  CAS  Google Scholar 

  32. van Voskuilen AC et al. (2006) Long term results of neuromodulation by sacral nerve stimulation for lower urinary tract symptoms: a retrospective single center study. Eur Urol 49: 366–372

    Article  CAS  Google Scholar 

  33. White WM et al. (2008) Sacral nerve stimulation for treatment of refractory urinary retention: long-term efficacy and durability. Urology 71: 71–74

    Article  Google Scholar 

  34. Elhilali MM et al. (2005) Sacral neuromodulation: long-term experience of one center. Urology 65: 1114–1117

    Article  Google Scholar 

  35. Shaker HS and Hassouna M (1998) Sacral root neuromodulation in idiopathic nonobstructive chronic urinary retention. J Urol 159: 1476–1478

    Article  CAS  Google Scholar 

  36. Aboseif S et al. (2002) Sacral neuromodulation in functional urinary retention: an effective way to restore voiding. BJU Int 90: 662–665

    Article  CAS  Google Scholar 

  37. Das AK et al. (2004) Improvement in depression and health-related quality of life after sacral nerve stimulation therapy for treatment of voiding dysfunction. Urology 64: 62–68

    Article  Google Scholar 

  38. Aboseif SR et al. (2007) Sacral neuromodulation: cost considerations and clinical benefits. Urology 70: 1069–1073

    Article  Google Scholar 

  39. Swinn MJ et al. (1999) Leg pain after sacral neuromodulation: anatomical considerations. BJU Int 84: 1113–1115

    Article  CAS  Google Scholar 

  40. Spinelli M et al. (2001) Chronic sacral neuromodulation in patients with lower urinary tract symptoms: results from a national register. J Urol 166: 541–545

    Article  CAS  Google Scholar 

  41. Hijaz A et al. (2006) Complications and troubleshooting of two-stage sacral neuromodulation therapy: a single-institution experience. Urology 68: 533–637

    Article  Google Scholar 

  42. Brazzelli M et al. (2006) Efficacy and safety of sacral nerve stimulation for urinary urge incontinence: a systematic review. J Urol 175: 835–841

    Article  Google Scholar 

  43. Van Voskuilen AC et al. (2007) Medium-term experience of sacral neuromodulation by tined lead implantation. BJU Int 99: 107–110

    Article  Google Scholar 

  44. Dindo D et al. (2004) Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 240: 205–213

    Article  Google Scholar 

  45. Everaert K et al. (2000) Patient satisfaction and complications following sacral nerve stimulation for urinary retention, urge incontinence and perineal pain: a multicenter evaluation. Int Urogynecol J Pelvic Floor Dysfunct 11: 231–235

    Article  CAS  Google Scholar 

  46. Sutherland SE et al. (2007) Sacral nerve stimulation for voiding dysfunction: one institution's 11-year experience. Neurourol Urodyn 26: 19–28

    Article  Google Scholar 

  47. Deng DY et al. (2006) Failure of sacral nerve stimulation due to migration of tined lead. J Urol 175: 2182–2185

    Article  Google Scholar 

  48. Kessler TM et al. (2005) Bilateral migration of sacral neuromodulation tined leads in a thin patient. J Urol 173: 153–154

    Article  Google Scholar 

  49. Spinelli M et al. (2005) New tined lead electrode in sacral neuromodulation: experience from a multicentre European study. World J Urol 23: 225–229

    Article  Google Scholar 

  50. Scheepens WA et al. (2002) Unilateral versus bilateral sacral neuromodulation in patients with chronic voiding dysfunction. J Urol 168: 2046–2050

    Article  CAS  Google Scholar 

  51. Maher MG et al. (2007) Bilateral caudal epidural neuromodulation for refractory urinary retention: a salvage procedure. J Urol 177: 2237–2240

    Article  Google Scholar 

  52. Fowler CJ et al. (2000) Studies of the latency of pelvic floor contraction during peripheral nerve evaluation show that the muscle response is reflexly mediated. J Urol 163: 881–883

    Article  CAS  Google Scholar 

  53. Schurch B et al. (2003) Electrophysiological recordings during the peripheral nerve evaluation (PNE) test in complete spinal cord injury patients. World J Urol 20: 319–322

    CAS  PubMed  Google Scholar 

  54. van der Pal F et al. (2006) Current opinion on the working mechanisms of neuromodulation in the treatment of lower urinary tract dysfunction. Curr Opin Urol 16: 261–267

    Article  Google Scholar 

  55. Riazimand SH and Mense S et al. (2004) A rat model for studying effects of sacral neuromodulation on the contractile activity of a chronically inflamed bladder. BJU Int 94: 158–163

    Article  Google Scholar 

  56. Riazimand SH and Mense S (2005) Interaction between neurotransmitter antagonists and effects of sacral neuromodulation in rats with chronically hyperactive bladder. BJU Int 96: 900–908

    Article  CAS  Google Scholar 

  57. Minardi D et al. (2008) Activity and expression of nitric oxide synthase in rat bladder after sacral neuromodulation. Int J Immunopathol Pharmacol 21: 129–135

    Article  CAS  Google Scholar 

  58. Wang Y and Hassouna MM (2000) Neuromodulation reduces c-fos gene expression in spinalized rats: a double-blind randomized study. J Urol 163: 1966–1970

    Article  CAS  Google Scholar 

  59. Shaker H et al. (2000) Role of C-afferent fibres in the mechanism of action of sacral nerve root neuromodulation in chronic spinal cord injury. BJU Int 85: 905–910

    Article  CAS  Google Scholar 

  60. Zhou Y et al. (2002) Change of vanilloid receptor 1 following neuromodulation in rats with spinal cord injury. J Surg Res 107: 140–144

    Article  CAS  Google Scholar 

  61. Wang Y et al. (2000) Neuromodulation reduces urinary frequency in rats with hydrochloric acid-induced cystitis. BJU Int 86: 726–730

    Article  CAS  Google Scholar 

  62. Groen J et al. (2006) Sacral neuromodulation in women with idiopathic detrusor overactivity incontinence: decreased overactivity but unchanged bladder contraction strength and urethral resistance during voiding. J Urol 175: 1005–1009

    Article  Google Scholar 

  63. Sievert KD et al. (2008) The early implantation of bilaterally sacral nerve modulators to prevent the neurogenic bladder malfunction in paraplegic patients [abstract 574]. Eur Urol Suppl 7: 214

    Article  Google Scholar 

  64. Blok BF et al. (2006) Different brain effects during chronic and acute sacral neuromodulation in urge incontinent patients with implanted neurostimulators. BJU Int 98: 1238–1243

    Article  Google Scholar 

  65. Leng WW and Chancellor MB (2005) How sacral nerve stimulation neuromodulation works. Urol Clin North Am 32: 11–18

    Article  Google Scholar 

  66. DasGupta R and Fowler CJ (2004) Urodynamic study of women in urinary retention treated with sacral neuromodulation. J Urol 171: 1161–1164

    Article  Google Scholar 

  67. Dasgupta R et al. (2005) Changes in brain activity following sacral neuromodulation for urinary retention. J Urol 174: 2268–2272

    Article  Google Scholar 

  68. Schultz-Lampel D et al. (1998) Experimental results on mechanisms of action of electrical neuromodulation in chronic urinary retention. World J Urol 16: 301–304

    Article  CAS  Google Scholar 

  69. Bannowsky A et al. (2003) Sacral neuromodulation in treatment of functional disorders of the lower urinary tract. An overview of basic principles, indications, outcomes [German]. Urologe A 42: 1357–1365

    Article  CAS  Google Scholar 

  70. Wyndaele JJ et al. (2000) Influence of sacral neuromodulation on electrosensation of the lower urinary tract. J Urol 163: 221–224

    Article  CAS  Google Scholar 

  71. Braun PM et al. (2002) Alterations of cortical electrical activity in patients with sacral neuromodulator. Eur Urol 41: 562–566

    Article  CAS  Google Scholar 

  72. Tai C et al. (2006) Pudendal-to-bladder reflex in chronic spinal-cord-injured cats. Exp Neurol 197: 225–234

    Article  Google Scholar 

  73. Vitton V et al. (2008) Colonosphincteric electromyographic responses to sacral root stimulation: evidence for a somatosympathetic reflex. Neurogastroenterol Motil 20: 407–416

    Article  CAS  Google Scholar 

  74. Chai TC et al. (2000) Percutaneous sacral third nerve root neurostimulation improves symptoms and normalizes urinary HB-EGF levels and antiproliferative activity in patients with interstitial cystitis. Urology 55: 643–646

    Article  CAS  Google Scholar 

  75. Gooneratne ML et al. (2008) Normalization of substance P levels in rectal mucosa of patients with faecal incontinence treated successfully by sacral nerve stimulation. Br J Surg 95: 477–83

    Article  CAS  Google Scholar 

Download references

Acknowledgements

TM Kessler is supported by a grant from the Swiss National Science Foundation. The work for this Review was undertaken at University College London Hospitals–University College London, which have received a proportion of funding from the UK Department of Health's National Institute for Health Research Biomedical Research Centres funding scheme. Charles P Vega, University of California, Irvine, CA, is the author of and is solely responsible for the content of the learning objectives, questions and answers of the Medscape-accredited continuing medical education activity associated with this article.

Author information

Authors and Affiliations

  1. and CJ Fowler is a Consultant and Professor of Uro-Neurology and the Head of the Department of Uro-Neurology, TM Kessler is a Clinical and Research Fellow, The National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation Trust, London, UK.,

    Thomas M Kessler & Clare J Fowler

Authors
  1. Thomas M Kessler
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Clare J Fowler
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Thomas M Kessler.

Ethics declarations

Competing interests

The authors declared that they have acted as consultants for Medtronic Inc., manufacturer of sacral neuromodulation devices.

Supplementary information

Rights and permissions

Reprints and permissions

About this article

Cite this article

Kessler, T., Fowler, C. Sacral neuromodulation for urinary retention. Nat Rev Urol 5, 657–666 (2008). https://doi.org/10.1038/ncpuro1251

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1038/ncpuro1251

This article is cited by

Search

Advanced search

Quick links

Nature Briefing

Sign up for the Nature Briefing newsletter — what matters in science, free to your inbox daily.

Get the most important science stories of the day, free in your inbox. Sign up for Nature Briefing