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Successful bilateral pudendal neuromodulation to treat male detrusor areflexia following severe pubic symphysis fracture, a case report
© Marinkovic et al. 2015
Received: 23 March 2015
Accepted: 29 October 2015
Published: 18 November 2015
A Drum Dock Manager in an auto manufacturing company suffers a pelvic fracture, severing the bulbar urethra and completely fracturing the right side of his pelvis.
He is unable to void without catheterization but has a complete sensation to void. Can neuromodulation help him achieve spontaneous voiding?
We reviewed the electronic medical record of Mr. M.E. from Detroit Medical Center following his 2012 forklift accident and subsequent orthopedic surgeries. He successfully underwent bilateral sacral neuromodulation, with a resulting max flow of 16.8 mls/sec and post-void residual urine of 50–100 mls. Unfortunately, he later presented with bilateral pocket and sacral lead infection, and both systems had to be removed. Six weeks later, M.E. had bilateral pudendal neurostimulation placement to avoid the previously infected areas. Max flow improved to 14.5 mls/sec and 0–50 mls residual urine. However, urodynamics proved that his Pdet at max flow was in excess of 120 cm of H20 pressure while he had been on finesteride and tamsulosin for the preceding five years for the management of his documented benign prostate hyperplasia symptoms. He underwent Green light laser transurethral resection of the prostate and had max flow improvement to 22.5 mls/second with zero residual urine with multiple straight catheterization confirmations.
Sacral neuromodulation may successfully correct traumatic urinary retention in male patients. Additionally, pudendal neuromodulation can be successfully utilized as a salvage method for an infected sacral neuromodulation impulse generator (IPG) and tined lead with a return to proper voiding.
Traumatic urethral injury may result in partial or total urinary retention in male patients. Clean intermittent catheterization or chronic indwelling Foley catheterization are frequently instituted to properly empty the bladder as a temporary or permanent treatment measure. However, after primary healing of 6 months or more, consideration may be given to the surgical treatment of urinary retention . In the literature, sacral neuromodulation has reportedly been utilized following surgical trauma but not blunt or penetrating trauma. We now report the first case in the literature utilizing bilateral sacral neuromodulation followed by bilateral pudendal neuromodulation after an industrial accident left our male patient with a severe pubic symphysis fracture and subsequent urinary retention.
Multichannel urodynamics report
1st Desire to Void
Strong Desire to Void
51 cm H2O
0 cm H2O
Cough Leak Point Pressure
Contracts external sphincter around a finger in his rectum, indicating that the pudendal nerve is working well
Treatment of complete detrusor areflexia has included Valsalva voiding, intermittent straight catheterization, chronic Foley catheterization, and most recently sacral neuromodulation. Women achieve higher success rates than men with sacral neuromodulation, but the use of pudendal neuromodulation [2–8], particularly dual pudendal neuromodulation for the treatment of detrusor areflexia, has not been described. Several physicians with whom I have communicated have stated that pudendal neuromodulation for male urinary retention does not work well. How sacral and pudendal neuromodulation work to treat both overactive bladder symptoms and, to a lesser extent, urinary retention has not been clearly defined. What is important to note is that the lower the voltage level achieved to elicit good motor provocation during sacral neuromodulation (bellows and ipsilateral big toe plantar flexion and potentially pudendal neuromodulation anal wink with an EMG documented EMG tracing at less than or equal to 3 volts at one or more leads) the better the end result for urinary retention and overactive bladder symptoms. Our patient had both bilateral sacral neuromodulation and bilateral pudendal neuromodulation and feels that pudendal neuromodulation has given him the closest sensation and performance to his normal voiding prior to the 2012 accident. He has also noticed an improvement in erections. While he was unable to have any erections without a phosphodiesterase 5 inhibitor for two years prior to the accident, he now can manage an erection without any medication. His voiding max flow and post-void residuals are now normal for his age, and he checks his post void residual via a home ultrasound device provided free of charge for his use. Pudendal neuromodulation is used as a salvage surgical operation for those who, with sacral neuromodulation, experience a decrease in efficacy and now fail to meet treatment expectations. Pudendal neuromodulation has not been described for urinary retention, but with our patient, the procedure appears to have improved his outcome after volitional voiding was not previously possible and his sacral implants became infected. We hope that with this patient’s continued success, we can appreciate the potential utilization of pudendal neuromodulation when sacral neuromodulation has failed for urinary retention.
Sacral neuromodulation may successfully correct traumatic urinary retention, in male patients. Additionally, pudendal neuromodulation can be successfully utilized as a salvage method for an infected sacral neuromodulation impulse generator (IPG), and tined lead with a return to proper voiding.
Written informed consent was obtained from the patient was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor of this journal.
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