What is Sacral Neuro Modulation (SNM) / Sacral Nerve Stimulation (SNS)?

Sacral Neuro Modulation (SNM) is designed to stimulate normal nerve function to aid continence. SNM is performed in two stages: the test stage and the implant stage.

Why am I incontinent of faeces?

When a person opens their bowels, the brain sends messages to the nerves, this allows the muscles to relax and open to aid defecation (passing a stool). When the communication between the brain and the nerves breakdown, a person may become incontinent.

Reasons for having Sacral Neuro Modulation (SNM)

The aim of this procedure is to restore faecal continence; this may be partially or fully restored.

Alternative treatments

You may wish not to have this procedure, if so your doctor/practitioner will discuss alternative treatments with yourself such as continuing with physiotherapy and taking medicines such as stool hardeners. However, this may not fully relieve your symptoms.

Information about diagnosis

Prior to having a Sacral Nerve Stimulator (SNS), you would have had the cause of your symptoms investigated by having a number of tests; these may include defecating proctogram (an xray image of your bowel movement) and measurements taken of the strength of the muscles in your bottom (endoanal ultrasound and anorectal physiology). Your surgeon would have reviewed these results and chosen the best treatment plan for your condition.

What does the procedure involve?

Stage 1 (Temporary wire) : first of all you will be given either a general anaesthetic or some sedation, you will then be positioned on your stomach on the operating theatre table, antimicrobial solution will be applied to your skin (to reduce bacteria on the skin surface) and sterile sheets applied around the operative site. Your doctor/practitioner will position a fine wire into a specific space in your lower back (along the side of a nerve) and then test the stimulation with the handheld controller to ensure it is correctly placed to achieve optimal stimulation. This will remain in place for 2-3 weeks. During which you will be given a simple continence diary to complete each day.

If Stage 1 stimulation has been successful and improved your incontinence, your clinician/practitioner may refer you on to have a permanent sacral neuro modulator implanted. This procedure will not be immediately after the temporary wire is removed as time must be given to allow sufficient healing of the skin.

Stage 2 (Permanent): Similarly to stage 1, you will either have a general anaesthetic or will be given some sedation and local anaesthetic to numb the area. You will then be positioned on to the operating table on your stomach. Your skin will be cleaned with antimicrobial solution (to reduce bacteria on the skin’s surface) and sterile drapes applied around the operation site. Your clinician will then with the aid of x-ray mark your skin with a surgical pen, to aid correct placement of your device. A thin wire will be inserted near the nerves in your lower back; this will be tested to ensure optimal stimulation is achieved. This wire is then connected to a small thin battery that will be inserted under the skin in the upper buttock. The skin will then be sutured closed and a dressing will be applied.

What about the anaesthetic?

You will meet with the anaesthetist prior to your surgery who will discuss the type of anaesthetic you will receive for this procedure, and answer any questions you may have. It will in most cases be either sedation or a general anaesthetic.

What happens before the operation?

You will be sent a letter or receive a telephone call inviting you to come into hospital for your surgery. You will be given information on when to come in (time and date) and where to report to (ward and hospital). Upon arrival into hospital you will be welcomed by the nursing staff, you will be shown to a room or bed space where you will be seen by a number of different professionals.

The ward nurse will complete some paperwork with you that is essential for your hospital stay such as personal details, allergies and next of kin; they may also take your blood pressure, pulse and temperature. You will also be seen by your surgeon who will complete a consent form with you and answer any questions you may have. You will also be seen by your anaesthetist who will explain about the anaesthetic and answer any questions you may have.

Once you have been seen by the team involved in your care, the ward nurse will give you a special gown to wear to theatre (you will need to remove all clothing including underwear before putting on the gown), and you may need to wear special compression stockings to prevent blood clots. You will have been asked to bring slippers/shoes and a dressing gown that you may wish to put on. When theatre is ready, you will be walked (if you are able) down to theatre with a member of staff. Where upon you will be welcomed by a member of the theatre team.

What happens after the operation?

You will return to the ward, where you will be given time to wake up and be given something to eat and drink. You will then be seen by your doctor/practitioner who will either turn the stimulator on (if Stage 1) or advise you when to return to hospital to have the stimulator turned on (if Stage 2 - generally in 2 weeks). You will also be given advice on how to use your handheld device (your practitioner will have already shown you this prior to surgery).

Discharge from hospital

Following your procedure you can expect to go home the same day or the following day. Following discharge you must ensure you do the following:

Do:

• Read your handheld device instruction booklet
• Complete your bowel diary
• Keep the dressings dry
• Avoid showering for 48 hours (then avoid getting the dressing wet)

Don’t:

• Have a bath (if Stage 1)
• Complete strenuous activities that may dislodged the wire

Frequently asked questions:

May I drive with the SNS?
Yes you can as long as you feel safe and can perform an emergency stop. It is recommended that you turn the modulator off whilst driving as this could potentially cause spasms in the nerves of your legs which may cause you to jump.

May I have sexual intercourse?
Yes as soon as you feel comfortable, care must be taken not to dislodge the wire if you have a temporary stimulator (Stage 1).

Should I change the dressings?
No, as the removal of dressings may dislodge the wire (Stage 1), if the dressings are becoming loose, you will have been given dressings to place over the existing dressings.

Can I go through shop or airport security gates?
Yes you can, however, always ensure you have your patient ID card with you to show security, and always check your modulator battery icon afterwards as the security gate may have turned the device off.

How long should I take off work?
It all depends on the kind of work you do, generally most people can return to normal activities within a couple of days, but if you have a very physically demanding job you may need longer off. Your clinician/practitioner will be able to advise you further on this.

Will the SNS keep me awake?
No, it should not affect your sleep, if you do find this then you may need to turn the stimulation down at night (just because you cannot feel the stimulation it does not mean it is not stimulating) or off.

Normally, you will have no restrictions while carrying out your activities. But you should avoid activities that involve sudden, excessive, or repetitive bending, twisting, bouncing, or stretching especially soon after the surgery. These movements could damage or move your implanted lead or affect the implanted neuro modulator.

We expect you to make a rapid recovery after your operation and to experience no serious problems. However, it is important that you should know about minor problems, which are common after this operation, and also about more serious problems that can occasionally occur.

What problems can occur after the operation?

Wound problems- we do not anticipate any wound problems with this procedure. However, your wound may become red and inflamed initially after surgery – this is generally the body’s natural healing response. If however, this goes on longer than a couple of days, is very sore or is discharging please ask your GP or practice nurse to check the wound.

Infection – infection in this procedure is very rare, but can happen. If you feel that it has become red and inflamed and has become very sore and/or discharging please see your GP or practice nurse.

Deep vein thrombosis (DVT)
Deep vein thrombosis is a possible problem, but is uncommon. If you are at particular risk then special precautions will be taken to reduce the risk. Moving your legs and feet as soon as you can after the operation and walking about early, all help to stop thrombosis occurring.

The risks of a general anaesthetic

General anaesthetics have some risks, which may be increased if you have chronic medical conditions, but in general they are as follows:

Common temporary side effects (risk of 1 in 10 to 1 in 100) include bruising or pain in the area of injections, blurred vision and sickness, these can usually be treated and pass off quickly.

Infrequent complications (risk of 1 in 100 to 1 in 10,000) include temporary breathing difficulties, muscle pains, headaches, damage to teeth, lip or tongue, sore throat and temporary problems with speaking.

Extremely rare and serious complications (risk of less than 1 in 10,000). These include severe allergic reactions and death, brain damage, kidney and liver failure, lung damage, permanent nerve or blood vessel damage, eye injury, and damage to the voice box. These are very rare and may depend on whether you have other serious medical conditions.

What should you do if you develop problems?

If wound problems please contact your GP or practice nurse.

If you develop stimulator problems please contact your Consultant’s secretary who will be able to arrange for somebody to help you with this.

Do you need to return to outpatients for a check?

• Stage 1 – removal of wire in 2-3 weeks
• Stage 2 – turning on of the device in 2 weeks

Who should you contact in an emergency?

Depending on the emergency contact either your GP or go to the accident and emergency department.