Sacral nerve stimulation





Definition

Sacral nerve stimulation, also known as sacral neuromodulation, is a procedure in which the sacral nerve at the base of the spine is stimulated by a mild electrical current from an implanted device. It is done to improve functioning of the urinary tract, to relieve pain related to urination, and to control fecal incontinence.


Purpose

As a proven treatment for urinary incontinence, sacral nerve stimulation (SNS) has recently been found effective in the treatment of interstitial cystitis, a disorder that involves hyperreflexia of the urinary sphincter. SNS is also used to treat pelvic or urinary pain as well as fecal incontinence.

A person's ability to hold urine or feces depends on three body functions:

  • a reservoir function represented by the urethra/bladder or colon
  • a gatekeeping function represented by the urethral or anal sphincter
  • the brain's ability to control urination, defecation, and nerve sensitivity

A dysfunction or deficiency in any of these components can result in incontinence. The most common forms of incontinence are stress urinary incontinence and urge incontinence. Stress incontinence is related to an unstable detrusor muscle that controls the urinary sphincter. When the detrusor muscle is weak, urine can leak out of the bladder from pressure on the abdomen caused by sneezing, coughing, and other movements. Urge incontinence is characterized by a sudden strong need to urinate and inability to hold urine until an appropriate time; it is also associated with hyperactivity of the urinary sphincter. Both conditions can be treated by SNS. SNS requires an implanted device that sends continuous stimulation to the sacral nerve that controls the urinary sphincter. This treatment has been used with over 1500 patients with a high rate of success. It was approved in Europe in 1994. The Food and Drug Administration (FDA) approved SNS for disturbances that are usually treated by augmentation of the sphincter muscle or implanting an artificial sphincter can benefit from electrical stimulation of the sacral nerve. Although the mechanism of SNS is not completely clear, researchers believe that the patient's control of the pelvic region is restored by the stimulation or activation of afferent fibers in the muscles of the pelvic floor.

Demographics

Urinary incontinence affects between 15% and 30% of American adults living in the community, and as many as 50% of people confined to nursing homes . It is a disorder that affects women far more frequently than men; 85% of people suffering from urinary incontinence are women. According to the chief of geriatrics at a Boston hospital, 25 million Americans suffer each year from occasional episodes of urinary or fecal incontinence.

Interstitial cystitis is less common than urinary or fecal incontinence but still affects 700,000 Americans each year. The average age of IC patients is 40; 25% of patients are younger than 30. Although 90% of patients diagnosed with IC are women, it is thought that the disorder may be underdiagnosed in men.

Description

Sacral nerve stimulation (SNS) is conducted through an implanted device that includes a thin insulated wire called a lead and a neurostimulator much like a cardiac pacemaker. The device is inserted in a pocket in the patient's lower abdomen. SNS is first tried on an outpatient basis in the doctor's office with the implantation of a test lead. If the trial treatment is successful, the patient is scheduled for inpatient surgery.

Permanent surgical implantation is done under general anesthesia and requires a one-night stay in the hospital. After the patient has been anesthetized, the surgeon implants the neurostimulator, which is about the size of a pocket stopwatch, under the skin of the patient's abdomen. Thin wires, or leads, running from the stimulator carry electrical pulses from the stimulator to the sacral nerves located in the lower back. After the stimulator and leads have been implanted, the surgeon closes the incision in the abdomen.


Diagnosis/Preparation

Incontinence significantly affects a patient's quality of life; thus patients usually consult a doctor when their urinary problems begin to cause difficulties in the workplace or on social occasions. A family care practitioner will usually refer the patient to a urologist for diagnosis of the cause(s) of the incontinence. Patients with urinary and fecal incontinence are evaluated carefully through the taking of a complete patient history and a physical examination . The doctor will use special techniques to assess the capacity of the bladder or rectum as well as the functioning of the urethral or anal sphincter in order to determine the cause or location of the incontinence. Cystoscopy , which is the examination of the full bladder with a scope attached to a small tube, allows the physician to rule out certain disorders as well as plan the most effective treatment. These extensive tests are especially important in diagnosing interstitial cystitis because all other causes of urinary urgency, frequency, and pain must be ruled out before surgery can be suggested. Cystoscopy is done under anesthesia and often works as a treatment for IC. Once the doctor has made the diagnosis of urinary incontinence due to sphincter insufficiency, he or she will explain and discuss the surgical implant with the patient. SNS may be tried out on a temporary basis. The same pattern of diagnosis and treatment is used for patients with IC and fecal incontinence. Temporary implants can help eliminate those patients who will not benefit from a permanent implant.

Aftercare

Following surgery, the patient remains overnight in the hospital. Antibiotics may be given to reduce the risk of infection and pain medications to relieve discomfort. The patient will be given instructions on incision care and follow-up appointments before he or she leaves the hospital.

Aftercare includes fine-tuning of the SNS stimulator. The doctor can adjust the strength of the electrical impulses in his or her office with a handheld programmer. The stimulator runs for about five to 10 years and can be replaced during an outpatient procedure. About a third of patients require a second operation to adjust or replace various elements of the stimulator device.


Risks

In addition to the risks of bleeding and infection that are common to surgical procedures, implanting an SNS device carries the risks of pain at the insertion site, discomfort when urinating, mild electrical shocks, and displacement or dislocation of the leads.


Normal results

Patients report improvement in the number of urinations, the volume of urine produced, lessened urgency, and higher overall quality of life after treatment with SNS. Twenty-two patients undergoing a three to seven-day test of sacral nerve stimulation on an outpatient basis reported significant reduction in urgency and frequency, according to the American Urological Association. Studies have indicated complete success in about 50% of patients. Sacral nerve stimulation is being used to treat fecal incontinence in the United States and Europe, with promising early reports. As of 2003, SNS is the least invasive of the recognized surgical treatments for fecal incontinence.


Morbidity and mortality rates

Sacral nerve stimulation has been shown to be a safe and effective procedure for the treatment of both urinary and fecal incontinence. Two groups of researchers, in Spain and the United Kingdom respectively, have reported that "the effects of neuromodulation are long-lasting and associated morbidity is low." The most commonly reported complications of SNS are pain at the site of the implant (15.3% of patients), pain on urination (9%), and displacement of the leads (8.4%).


Alternatives

There are three types of nonsurgical treatments that benefit some patients with IC:

  • Behavioral approaches. These include biofeedback, diet modifications, bladder retraining, and pelvic muscle exercises.
  • Medications. These include antispasmodic drugs, tricyclic antidepressants, and pentosan polysulfate sodium, which is sold under the trade name Elmiron. Elmiron appears to work by protecting the lining of the bladder from bacteria and other irritating substances in urine.
  • Intravesical medications. These are medications that affect the muscular tissues of the bladder. Oxybutynin is a drug that is prescribed for patients who are incontinent because their bladders fail to store urine properly. Capsaicin and resiniferatoxin are used to treat hyperreflexia of the detrusor muscle.

Surgical alternatives to SNS are considered treatments of last resort for IC because they are invasive, irreversible, and benefit only 30–40% of patients. In addition, some studies indicate that these surgeries can lead to long-term kidney damage. They include the following procedures:

  • Augmentation cystoplasty. In this procedure, the surgeon removes the patient's bladder and replaces it with a section of the bowel—in effect creating a new bladder. The patient passes urine through the urethra in the normal fashion.
  • Urinary diversion. The surgeon creates a tube from a section of the patient's bowel and places the ureters (tubes that carry urine from the kidneys to the bladder) in this tube. The tube is then attached to a stoma, or opening in the abdomen. Urine is carried into an external collection bag that the patient must empty several times daily.
  • Internal pouch. The surgeon creates a new bladder from a section of the bowel and attaches it inside the abdomen. The patient empties the pouch by self-catheterization four to six times daily.

Resources

books

Walsh, Patrick C., MD, et al., eds. Campbell's Urology , 8th ed. Philadelphia: W. B. Saunders Company, 2002.

periodicals

Elliott, Daniel S., MD. "Medical Management of Overactive Bladder." Mayo Clinic Proceedings 76 (April 2001): 353-355.

Ganio, E., A. Masin, C. Ratto, et al. "Short-Term Sacral Nerve Stimulation for Functional Anorectal and Urinary Disturbances: Results in 40 Patients: Evaluation of a New OPtion for Anorectal Functional Disorders." Disorders of the Colon and Rectum 44 (September 2001): 1261-1267.

Kenefick, N. J., C. J. Vaisey, R. C. Cohen, et al. "Medium-Term Results of Permanent Sacral Nerve Stimulation for Faecal Incontinence." British Journal of Surgery 89 (July 2002); 896-601.

Linares Quevedo, A. I., M. A. Jiminez Cidre, E. Fernandez Fernandez, et al. "Posterior Sacral Root Neuromodulation in the Treatment of Chronic Urinary Dysfunction. [in Spanish] Actas urologicas espanolas 26 (April 2002): 250-260.


organizations

American Urological Association (AUA). 1120 North Charles Street, Baltimore, MD 21201. (410) 727-1100. http://www.auanet.org .

National Association for Continence (NAFC). P. O. Box 1019, Charleston, SC 29402-1019. (843) 377-0900. http://www.nafc.org .

National Kidney Foundation. 30 East 33rd Street, Suite 1100, New York, NY 10016. (800) 622-9010 or (212) 889-2210. http://www.kidney.org .

National Kidney and Urologic Diseases Information Clearinghouse (NKUDIC). 3 Information Way, Bethesda, MD 20892-3580.

other

Interstitial Cystitis Association. Sacral Nerve Stimulation Can Relieve Interstitial Cystitis, Studies Suggest . <www.ichelp.com/research/SacralNerveStimulationCanRelieveIC.html& x003E; .

Mayo Clinic. Sacral Nerve Stimulation . http://www.mayoclinic.org/incontinence-jax/sacralstim.html.


Nancy McKenzie, PhD

WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?



SNS devices are implanted under general anesthesia by urologists, who are physicians specializing in treating disorders of the urinary tract. The procedure is usually performed in a hospital.

QUESTIONS TO ASK THE DOCTOR



  • Am I likely to benefit from SNS?
  • How many stimulators have you implanted?
  • How many of your patients consider SNS a successful treatment?
  • What side effects have your patients reported?


User Contributions:

christine
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Apr 24, 2006 @ 8:08 am
I am due to have this op at the end of this week, I am in the UK.
I know it is very new over here. I am a little concerned, as I don't think my specialist has done any, (or only a couple) I have asked to speak to someone who has had it, but there was no one available.
After the initial implant, and healing, will I always be aware of the battery pack. I had the pre-op tests, one failed and the second one was ok.(This was for fecal incontinence.
Also since waiting for the main op I have been much better, could this be where the muscle was tightened during the test, or just coincidence?
Also I understood it was to be fitted in my hip area, yet the web tells of in the abdomen.
Carol Richardson
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Jan 27, 2009 @ 9:09 am
I am 38 yrs old and have the sacral nerve stimulator in place as we speak...it was fitted on thursday (it is the first op..with the needle connected to a portable machine...you have had this op obviously...can you tell me did it make you feel sick....because i dont want it if its gonna make me feel like this for ever.
Linda
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Mar 19, 2009 @ 9:09 am
I had vaginal surgery a year ago for cronic inflamation for no apparent reason my test were all normal.they removed tissue the size of a quarter in my vestibul wall. so goes the term vulvodynia.but now I am greater pelvic pain, probably pudendal neuralgia,although they don't want to say that for sure My gynecologist suggest that I check on a new procedure called interstim she says I may be a candidate for it? I dont know who to see.pills dont work since the surgery.I am 64 years old. in cronic pain way over two years. could interstim help me? I am desperate.would pelvic floor pain make me make me investigate this.who would I see??
jen
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Jun 25, 2009 @ 3:15 pm
ive suffered from urge *feacial* incontinece for a number of years, i had a sphinchter repair, that lasted about 5 years, i recently had the test stimulater, that went well, i now have the perm implant, that was only inserted on monday, im still in a bit of pain because of the surgery, i go back on monday to *get switched on*, its not that bad to feel the pulses, iff it makes your life better, im only 39 and i have had a wasted life, im looking forward to being able to go out and have a life again :)
maria
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Jul 6, 2009 @ 8:20 pm
hi ive not long just had had the first op im 19 the youngest they have had to have the op as it it is more commen in older people i was born with brain damaged but was ok til i hit pubity and i developed weakness in my left side,kidney damage and epilepsy and when i hit about 12 my bladder colapsed and later my bowels after about 13 operations i was sent to london nurological hospital which was only an adult hospital only being 14 i was looky that someone would have a look and from then on my bladder condition was diagnosed fowlers syndrone anyway i was tolsd about the surdary then but i was told i would have to be 21 but just after my 18th i recieved a letter telling me that they had brought the age down and they offerd me to speak to someone in wakefield about having one i was granted to have the trial and it seem to work a lot of things some that wasnt unexpected i have not been aproved to have the pernemant one just waiting for a date

i will give both hospitals 10/10 not just because the op but the way i was treated i have been to many hospitals before and have had bad experences in some but both the london hosp and wakefield none as pinderfields they were amazing listens to everyone

hope this helps
from maria
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Jul 4, 2010 @ 6:06 am
I am due to have the SNS for consipation. I am very worried as it is a trail program, I was wanting to know if you have a feed back and if SNS is successful for the bowel.
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Jul 25, 2010 @ 6:18 pm
Hi Cathy, I had the trial for SNS back in April which worked very very well, and i've just had the permanant one put in last week, any questions feel free to email me x
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Sep 11, 2010 @ 9:21 pm
where do you go to have this sns done and a urology i live in richmond ky
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Oct 2, 2010 @ 12:00 am
I would like some information on SNS for fecal incontinence, the names of the physicians who are doing this and how many they have done and their success rate. Thank you!
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Oct 13, 2010 @ 10:10 am
Does this device work fro spina bifida patients that had surgical repair but have urinary and bowel problems?? Is this done in Australia? Thanks for any information.
julie johnson
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Dec 18, 2010 @ 7:07 am
HI nearly 3wks ago i had a permanent SNS for fecal incontinence. I found the temp procedure made my life much easier without panicking when i went out i couldnt get to a toilet. Now i am pleased i have had the permenent done and that i can live my life as a normal person. It has been quite painfull getting up and down after the operation and even now i know if i have pushed myself to much but i wouldnt swap the pain for anything., I wonder did anyone else seem to suffer with back and bum ache for a long period of time?

I had my op done at whitechapel hospital in london and i cant thank all the team there enough as i suffered with this for at least 5years thinking it was normal after having children now i know it isnt.
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Jan 25, 2011 @ 3:15 pm
Hi

I had the operation two weeks ago and I am really suffering with backache. Does anyone know if this is normal? I have not yet had the SNS turned on. Thanks Suznane
Jean Nicholls
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Feb 16, 2011 @ 6:06 am
Hi
My specialist in Brisbane Australia, has suggested that i need a SNS for my chronic problem with fecal incontinence. The muscles and anal sphincter in my rectum have wasted away, does anyone know if the SNS helps build muscle that has wasted? Has anyone had the device for any length of time? and if so what are the long term effects? Oh and what can i expect with the trial that is planned? I have so many questions that i need to ask someone who has actually experienced a SNS.
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Feb 25, 2011 @ 5:17 pm
Ive just had the Tined Lead Test last week, so far Im able to pass small amounts of urine and have the sensation back that I need to go. I have not passed any urine myself for 9 years after an operation that went wrong. I am in considerable pain at the site of the surgery but also I have a sciatic pain in my buttocks and down my leg, Is this normal? I would recommend the trial as I think this could change my life and hopefully others.
Thanks
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Feb 28, 2011 @ 8:20 pm
I had the sacral nerve stimulator for over a year. I did not feel sick at all. Both of my procedures were done outpatient. I did not stay in the hospital. I found the first surgery to actually hurt the most. I had a small wire coming out of the top of my behind. I call it digging the tunnel. The wire is put close to the nerve and it has to get there. The second surgery was also outpatient. I have a 3 inch scar at the top of my behind. If you wear low cut pants, it may land on the scar. Just out of no where I will have pain around the machine. It is sore for a couple of days. It doesn't hurt a lot just annoying. I would do it again.
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Mar 24, 2011 @ 5:05 am
Hi I have had the temp one in for a week now and it has changed my life. I was crushed 2 years ago and have suffered pain and muscule wasting with nerves that don't fire properly. The pain is now 80% gone and I get fitted for my permanent one next week and can't wait! I am in NZ and they tell me I am the 13th to have this done here so still quite new for us. I have a bit of surgery pain but it is nothing compared to what I have been living with for the last 2 years. I am so grateful that they have this device available.
Thanks :)
Marilyn
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Apr 30, 2011 @ 4:16 pm
Hi Lisa,

Great to hear of your sucess and that you had little side affects. So nice to hear some positive feedback, as a lot of the comments are talking about the pain and discomfort experienced.

I live in Australia, and the procedure has only recently been accepted by our government here ( cost to them $16,000!) Cost to me around $2,000-.

I have my trial test procedure this coming Tuesday and cant wait! After many many years of bladder incontinence which has made my life quite difficult, Im keeping all my fingers and toes crossed that it works for me. If so, I go back in for perm. op 2 weeks later. Both procedures are undertaken through day surgery.

I am 56 and my hubby turns 60 next weekend so 3 couples are coming up to Queensland where we live from interstate to see him as a surprise. I am a little worried how I will be,I didnt want to put off the procedure though.
We are planning to go out for dinner etc. so I will be entertaining all weekend. (One couple arrive 2 days after my procedure) Im also having my 2 grandsons 3 & 4 for a couple of hours the next day, but, intend not doing anything strenuous with them, and wont pick them up.

Did you find the external box annoying? How does it attach? - clipped to a belt Im guessing. Did it look quite obvious under your clothes ( I will of course wear loose clothing) Do you have to give the device your full attention? or will I be able to go on with life as normal? What about sleeping with it?

Would love to hear your thoughts if you have the time.
Many Thanks
Marilyn
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May 12, 2011 @ 9:21 pm
my doctor has recommended this procedure for me due to chronic pain associated with interestitial cystitis. she says she has a patient who had it done and was off all meds within a year and pain free. i would love to hear from anyone who has had chronic pain in the pelvic floor (my pain can range from my lower legs to my rib cage on bad days). i'm only 38 years old. help!

nancy
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Jul 23, 2011 @ 2:14 pm
My consultant has recommended sacral nerve stimulation for fecal incontinence and I am wondering about how much activity you can do after it is fitted. I am a keen horse rider and can't imagine not riding again. Can you carry on as normal or do you have to be careful with it. Can you lift etc too?
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Oct 2, 2011 @ 12:12 pm
Hi Gill, I have had 2 SNS (1 in ea buttock) to control pain & urinary probs due to Interstitial Cystitis since Jan 2011. Unfortunately horse riding & ski-ing are two of the things they recommend you never do again. (I used to do both) The risk of dislodging or damaging the batteries and/or wires is too great.The only thing I can say is hopefully the absence of pain & problems with faecal incontinence will be worth the sacrifice? Hope all goes well , Jenny Smedley
ays
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Oct 18, 2011 @ 5:05 am
i have had my sns for the past 16 months, for bowl control. For me this has improved my life greatly with little discomfort in the operation. ok you do have to be mindfull the pack is just under the skin. mine is on my bottom. I have found finding the right setting has taken a while if im too high going throught security doors can make me jump. It dosnt make me feel sick as i thought it might my own experience is positve and If suggested to anyone I would highly recommend! :)
gmc
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Nov 21, 2011 @ 7:19 pm
I am 13 and i have tried 5 different meds. and none have worked so now we have to make the choice of this of biofeedback and retraining but that would take 2 hours a week away from school and that would not work. So we are leaning toward this is it diffrent in children and teens?
Lani
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Jan 6, 2012 @ 7:19 pm
I have had I.c. For 10 years and suffered considerably with it. All meds failed to help. Two years ago my urologist at USC implanted the SNS. It was heaven (approx. 70% improvement) for 2 weeks until an auto accident dislodged it. After trying other options I am now getting my second SNS...and praying for another success. Yes you have discomfort at the incision site ,etc., but the positives so outweigh the negatives if all goes well. Just can't imagine not trying it! I am a 63 year old female with a lot of life to live! I particularly hope and pray for you young patients out there. Get a doctor and a Medtronics rep that has done many of these.
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Jan 17, 2012 @ 11:11 am
I just had the trial sacral stimulator put in on 1/12/12 at Jefferson Hosp. in Philly. I'm getting slight improvement. Should I go ahead with having it put in permanently? Is it a long procedure to have the battery implanted and is it painful afterwards. Thank you.
Martha T
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Mar 4, 2012 @ 5:17 pm
I had a Medtronic NeuroStimulator put in in 2010. I have lost my instruction booklet on how to increase the pulsation. Does anyone know how to find a copy online? I have sent a message to the company but don't really want to wait for a response seeing the thing isn't working right now. If you can help please let me know.

Thank you!
Harpreet Singh
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Mar 30, 2012 @ 2:02 am
KINDLY LET ME KNOW THE NAMES OF HOSPITALS IN INDIA
WHO ARE PERFORMING TREATMENT OF INCONTINENCE BY SACRAL NERVE STIMULATION METHOD.

THANKS A LOT
brian dawson
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Oct 12, 2012 @ 7:19 pm
CAN SOMEONE TELL ME WHO PERFORMS THIS PROCEEDURE IN NEW ZEALAND ,PREFERABLY IN THE WAIKATO REGION, THANKYOU.
Al Lyons
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Mar 21, 2013 @ 10:10 am
I had the SNS procedure done (temporarily)in late Jan. It was done in the late afternoon and that night I got pains in my left leg & butt where the wires were inserted. By the next day I couldn't walk up the stairs due to the pain in my leg. That day the doctor's office called & I told them about the pain & was told to unplug the left wire & try the right wire. After 3 days I went back to the doctors office to have the wires removed. While removing he wires the doctor said that the left wire was hardly inserted. I told him about the pain in my left side & leg & he said that it had nothing to do with the procedure. He said that I might have a slipped disc & to go get a MRI. He also prescribed some muscle relaxers for me, but that didn't help. The pain clinic prescribed a MRI & it came back negative. By now the pain is severe (can't sleep or walk). The pain clinic gave me some medicated cream to try on my backside a& told me to go to my family doctor.I went to him & he prescibed prednisone & it is not helping. Now I can't sit,sleep or walk, the pain is severe. The procedure didn't work & I still get up every 2 hours at night. I need help! What do I do now?
lil bell
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Mar 26, 2013 @ 4:16 pm
Hi Al. Where abouts were you getting the leg pain? I had my temp sns fitted yesterday. The pain in the front of my left leg is unreal! I've turned my machine off for now until I can contact my consultant in the morning.
Al
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May 7, 2013 @ 1:13 pm
Hi Lil. The pain starts in my butt where the wires were inserted. When I sit or lay on my left side, the pain goes down my leg (front & back). The pain is terrible. I finally have an appointment with a specialist in a couple weeks that was recommended by my Urologist. Good luck.
melissa
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May 9, 2013 @ 2:02 am
HELLO IM A 25 YR OLD FEMALE IN THE US MY DOCTOR RECOMMENDED THIS SURGERY BECAUSE I HAVE TRIED ALL THE MEDICATIONS FOR MY IC I WORK AT A HOSPITAL AND AM NOT SURE IF I SHOULD GO THROUGH WITH IT WOULD I BE ABLE TO RETURN TO WORK? I AM A CNA AND DO ALORT OF LIFTING. ALSO DOES ANYONE KNOW IF THIS SURGERY EFFECTS THE CHANCES OF MY CONCIEVING A CHILD?

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