Pelvic floor activation upon stimulation of the sacral spinal nerves in sacral neuromodulation patients.

Publisher: Alan R. Liss Country of Publication: United States NLM ID: 8303326 Publication Model: Print-Electronic Cited Medium: Internet ISSN: 1520-6777 (Electronic) Linking ISSN: 07332467 NLM ISO Abbreviation: Neurourol Urodyn Subsets: MEDLINE

Original Publication: New York : Alan R. Liss, c1982-

Electric Stimulation*; Lumbosacral Plexus/*physiology ; Muscle, Skeletal/*physiology ; Pelvic Floor/*physiology; Adult ; Aged ; Electromyography/methods ; Female ; Humans ; Middle Aged ; Sacrum/physiology

Purpose: To assess the activation of the different parts of the pelvic floor muscles (PFM) upon electrical stimulation of the sacral spinal nerves while comparing the different lead electrode configurations.
Material and Methods: PFM electromyography (EMG) was recorded using an intravaginal multiple array probe with 12 electrodes pairs, which allows to make a distinction between the different sides and depths of the pelvic floor. In addition concentric needle EMG of the external anal sphincter was performed to exclude far-field recording. A medtronic InterStim tined lead (model 3889) was used as stimulation source. Standard SNM parameters (monophasic pulsed square wave, 210 microseconds, 14 Hz) were used to stimulate five different bipolar electrode configurations (3+0-/3+2-/3+1-/0+3-/1+3-) up to and around the sensory threshold. Of each EMG signal the stimulation intensity needed to evoke the EMG signals as well as its amplitude and latency were determined. Linear mixed models was used to analyse the data.
Results: Twenty female patients and 100 lead electrode configurations were stimulated around the sensory response threshold resulting in 722 stimulations and 12 times as many (8664) EMG recordings. A significant increase in EMG amplitude was seen upon increasing stimulation intensity (P < .0001). Large differences were noted between the EMG amplitude recorded at the different sides (ipsilateral>posterior>anterior>contralateral) and depths (deep>center>superficial) of the pelvic floor. These differences were noted for all lead electrodes configurations stimulated (P < .0001). Larger EMG amplitudes were measured when the active electrode was located near the entry point of the sacral spinal nerves through the sacral foramen (electrode #3). No differences in EMG latency could be withheld, most likely due to the sacral neuroanatomy (P > .05).
Conclusions: A distinct activation pattern of the PFM could be identified for all stimulated lead electrode configurations. Electrical stimulation with the most proximal electrode (electrode #3) as the active one elicited the largest PFM contractions.
(© 2020 Wiley Periodicals LLC.)

Brooks JD. Anatomy of the Lower Urinary Tract and Male Genitalia. In: Walsh PC, Retik AB, Vaughan ED, Wein AJ, eds. Campbell's Urology. 8th ed. Philadelphia, PE: WB Saunders; 2002:54-55.
Baader B, Herrmann M. Topography of the pelvic autonomic nervous system and its potential impact on surgical intervention in the pelvis. Clin Anat. 2003;16(2):119-130.
Colombel M, Droupy S, Paradis V, Lassau JP, Benoit G. Caverno-pudendal nervous communicating branches in the penile hilum. Surg Radiol Anat. 1999;21(4):273-276.
Walsh PC, Donker PJ. Impotence following radical prostatectomy: insight into etiology and prevention. J Urol. 1982;128(3):492-497.
Vaganée D, Kessler TM, Van de Borne S, De Win G, De Wachter S. Sacral neuromodulation using the standardized tined lead implantation technique with a curved vs a straight stylet: 2-year clinical outcomes and sensory responses to lead stimulation. BJU Int. 2018;123(5A):E7-E13.
Goldman HB, Lloyd JC, Noblett KL, et al. International Continence Society best practice statement for use of sacral neuromodulation. Neurourol Urodyn. 2018;37:1823-1848.
Vaganée D, Van de Borne S, Voorham-van der Zalm P, Voorham J, Fransen E, De Wachter S. Pelvic floor muscle electromyography as a guiding tool during lead placement and (re)programming in sacral neuromodulation patients: validity, reliability, and feasibility of the technique. Neuromodulation: Technol Neural Interface. 2020. https://doi.org/10.1111/ner.13177.
Gordon D, Robertson E, Caldwell GE, Hamill J, Kamen G, Whittlesey SN. Research Methods in Biomechanics. 2nd ed. Champaign, IL: Human Kinetics; 2013.
Matzel KE, Chartier-Kastler E, Knowles CH, et al. Sacral neuromodulation: standardized electrode placement technique. Neuromodulation. 2017;20:816-824.
Voorham-van der Zalm PJ, Voorham JC, van den Bos TW, et al. Reliability and differentiation of pelvic floor muscle electromyography measurements in healthy volunteers using a new device: the Multiple Array Probe Leiden (MAPLe). Neurourol Urodyn. 2013;32(4):341-348.
Cohen BL, Tunuguntla HS, Gousse A. Predictors of success for first stage neuromodulation: motor versus sensory response. J Urol. 2006;175(6):2178-2180.
Vaganee D, Voorham J, Voorham-van der Zalm P, De Wachter S. Needle placement and position of electrical stimulation inside sacral foramen determines pelvic floor electromyographic response-implications for sacral neuromodulation. Neuromodulation. 2019;22:709-715.
Thor KB, Morgan C, Nadelhaft I, Houston M, De Groat WC. Organization of afferent and efferent pathways in the pudendal nerve of the female cat. J Comp Neurol. 1989;288(2):263-279.
Ueyama T, Arakawa H, Mizuno N. Central distribution of efferent and afferent components of the pudendal nerve in rat. Anat Embryol. 1987;177(1):37-49.
Ueyama T, Mizuno N, Nomura S, Konishi A, Itoh K, Arakawa H. Central distribution of afferent and efferent components of the pudendal nerve in cat. J Comp Neurol. 1984;222(1):38-46.
Wunderlich M, Swash M. The overlapping innervation of the two sides of the external anal sphincter by the pudendal nerves. J Neurol Sci. 1983;59(1):97-109.
Bennett MVL, Zukin RS. Electrical coupling and neuronal synchronization in the mammalian brain. Neuron. 2004;41(4):495-511.
Jost WH. Electrostimulation in fecal incontinence: relevance of the sphincteric compound muscle action potential. Dis Colon Rectum. 1998;41(5):590-592.
Barber MD, Bremer RE, Thor KB, Dolber PC, Kuehl TJ, Coates KW. Innervation of the female levator ani muscles. Am J Obstet Gynecol. 2002;187(1):64-71.
Matzel KE, Schmidt RA, Tanagho EA. Neuroanatomy of the striated muscular anal continence mechanism. Implications for the use of neurostimulation. Dis Colon Rectum. 1990;33(8):666-673.
Percy JP, Neill ME, Swash M, Parks AG. Electrophysiological study of motor nerve supply of pelvic floor. Lancet. 1981;1(8210):16-17.
Wallner C, van Wissen J, Maas CP, Dabhoiwala NF, DeRuiter MC, Lamers WH. The contribution of the levator ani nerve and the pudendal nerve to the innervation of the levator ani muscles: a study in human fetuses. Eur Urol. 2008;54(5):1136-1142.
Hamdy S, Enck P, Aziz Q, Uengoergil S, Hobson A, Thompson DG. Laterality effects of human pudendal nerve stimulation on corticoanal pathways: evidence for functional asymmetry. Gut. 1999;45(1):58-63.
Su X, Cutinella M, Agran JE, Dinsmoor DA. Comparison of active stimulating electrodes of sacral neuromodulation. Neuromodulation. 2017;20:799-806.
Jacobs SA, Lane FL, Osann KE, Noblett KL. Randomized prospective crossover study of interstim lead wire placement with curved versus straight stylet. Neurourol Urodyn. 2014;33(5):488-492.
Vaganée D, Voorham J, Panicker JN, et al. Neural pathway of bellows response during SNM treatment revisited: conclusive evidence for direct efferent motor response. Neurourol Urody. 2020;39(5):1576-1583.

Keywords: neuromodulation; new instrumentation; overactive bladder; pelvic floor; pelvic organ dysfunction; prospective study; sacral neuromodulation; sacral neurostimulation; urinary incontinence; urinary retention

Date Created: 20200626 Date Completed: 20210401 Latest Revision: 20210401

20250114

10.1002/nau.24425

32585049