Sacral neuromodulation treating chronic pelvic pain: a meta-analysis and systematic review of the literature

Abstract

Introduction and hypothesis

Sacral neuromodulation (SNM) is gaining popularity as a treatment option for chronic pelvic pain (CPP). Our hypothesis is that SNM is effective in improving CPP.

Methods

A systematic search was conducted through September 2018. Peer-reviewed studies using pre- and postpain intensity scores were selected. The primary outcome was pain improvement on a 10-point visual analog scale (VAS) (adjusted or de novo) in patients with CPP. Secondary outcomes included comparing SNM approaches and etiologies and evaluating lower urinary tract symptoms (LUTS).

Results

Fourteen of 2175 studies, evaluating 210 patients, were eligible for further analysis. The overall VAS pain score improvement was significant [weighted mean difference (WMD) −4.34, 95% confidence interval (CI) = −5.22, to−3.64, p < 0.0001)]. Regarding SNM approach, both standard and caudal approaches had significant reduction in pain scores: WMD −4.32, CI 95% = −5.32, to −3.31 (p < 0.001) for the standard approach, compared with WMD −4.63, 95% CI = −6.57 to −2.69 (P < 0.001), for the caudal approach (p = 0.75). While significant improvement in pain was observed both in patients with and without interstitial cystitis/bladder pain syndrome (IC/BPS), the observed improvement was lower in patients with (WMD −4.13, CI 95% −5.36 to −2.90 versus without (WMD −5.72, CI 95% = −6.18, to−5.27) IC/BPS (p = 0.02). SNM was effective in treating voiding symptoms (frequency, urgency, nocturia) associated with IC/BPS (all p < 0.01).

Conclusions

SNM is an effective therapy for CPP in both IC/BSP and non-IC/BSP patients, with better results in non-IC/BSP patients. Outcomes of the antegrade caudal approach were comparable with the standard retrograde approach.

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Abbreviations

SNM:

Sacral neuromodulation

CPP:

Chronic pelvic pain

VAS:

Visual analog scale

IC:

Interstitial cystitis

BPS:

Bladder pain syndrome

WMD:

Weighted mean difference

PNE:

Percutaneous nerve evaluation

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Correspondence to Sherif A. El-Nashar.

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Appendix

Appendix

Database(s): Ovid MEDLINE(R) and Epub Ahead of Print, In-Process & Other Non-Indexed Citations and Daily 1946 to 14 September 2018.

Search Strategy:

No. Searches Results
1 exp Electric Stimulation Therapy/ 72,449
2 (electric adj2 stimulation*).ti,ab. 5183
3 (nerve adj2 stimulation*).ti,ab. 21,658
4 Neuromodulation*.mp. 6090
5 neurostimulat*.mp. 2998
6 or/1–5 98,181
7 URINARY INCONTINENCE/or FECAL INCONTINENCE/or URINARY INCONTINENCE, URGE/or URINARY INCONTINENCE, STRESS/ 37,753
8 incontinence.ti,ab. 42,912
9 incontinent.ti,ab. 3853
10 exp Urinary Bladder Diseases/ 95,824
11 bladder.ti,ab. 142,717
12 cystitis.ti,ab. 10,417
13 Urination Disorders/ 10,985
14 (urin* adj2 disorder*).ti,ab. 1609
15 Pelvic Pain/ 4796
16 “pelvic pain”.ti,ab. 8048
17 or/7–16 230,545
18 exp SACRUM/ 8306
19 sacrum.ti,ab. 4813
20 sacral.ti,ab. 15,321
21 or/18–20 22,162
22 6 and 17 and 21 1512
23 limit 22 to animals 150
24 22 not 23 1362
25 limit 24 to (case reports or comment or editorial or letter) 148
26 24 not 25 1214
27 limit 26 to (english language and last 30 years) 1061
28 from 27 keep 1–1061 1061

PubMed Medline

(((((((((((Electric Stimulation Therapy[MeSH Terms]) OR electric stimulation*[Title/Abstract]) OR nerve stimulation*[Title/Abstract]) OR Neuromodulation*) OR neurostimulat*[Title/Abstract])) AND ((((((((((((((URINARY INCONTINENCE[MeSH Terms]) OR FECAL INCONTINENCE[MeSH Terms]) OR urinary incontinence, urge[MeSH Terms]) OR urinary incontinence, stress[MeSH Terms])) OR incontinence[Title/Abstract]) OR incontinent[Title/Abstract]) OR Urinary Bladder Diseases[MeSH Terms]) OR bladder[Title/Abstract]) OR cystitis[Title/Abstract]) OR Urination Disorders[MeSH Terms]) OR Urination Disorder*[Title/Abstract]) OR “Pelvic Pain”[Mesh:noexp]) OR pelvic pain[Title/Abstract])) AND (((SACRUM[MeSH Terms]) OR sacrum[Title/Abstract]) OR sacral[Title/Abstract]))) NOT (((((((((Electric Stimulation Therapy[MeSH Terms]) OR electric stimulation*[Title/Abstract]) OR nerve stimulation*[Title/Abstract]) OR Neuromodulation*) OR neurostimulat*[Title/Abstract])) AND ((((((((((((((URINARY INCONTINENCE[MeSH Terms]) OR FECAL INCONTINENCE[MeSH Terms]) OR urinary incontinence, urge[MeSH Terms]) OR urinary incontinence, stress[MeSH Terms])) OR incontinence[Title/Abstract]) OR incontinent[Title/Abstract]) OR Urinary Bladder Diseases[MeSH Terms]) OR bladder[Title/Abstract]) OR cystitis[Title/Abstract]) OR Urination Disorders[MeSH Terms]) OR Urination Disorder*[Title/Abstract]) OR “Pelvic Pain”[Mesh:noexp]) OR pelvic pain[Title/Abstract])) AND (((SACRUM[MeSH Terms]) OR sacrum[Title/Abstract]) OR sacral[Title/Abstract])) AND ((Case Reports[ptyp] OR Comment[sb] OR Editorial[ptyp] OR Letter[ptyp]))))) NOT (((((((((((Electric Stimulation Therapy[MeSH Terms]) OR electric stimulation*[Title/Abstract]) OR nerve stimulation*[Title/Abstract]) OR Neuromodulation*) OR neurostimulat*[Title/Abstract])) AND ((((((((((((((URINARY INCONTINENCE[MeSH Terms]) OR FECAL INCONTINENCE[MeSH Terms]) OR urinary incontinence, urge[MeSH Terms]) OR urinary incontinence, stress[MeSH Terms])) OR incontinence[Title/Abstract]) OR incontinent[Title/Abstract]) OR Urinary Bladder Diseases[MeSH Terms]) OR bladder[Title/Abstract]) OR cystitis[Title/Abstract]) OR Urination Disorders[MeSH Terms]) OR Urination Disorder*[Title/Abstract]) OR “Pelvic Pain”[Mesh:noexp]) OR pelvic pain[Title/Abstract])) AND (((SACRUM[MeSH Terms]) OR sacrum[Title/Abstract]) OR sacral[Title/Abstract]))) NOT (((((((((Electric Stimulation Therapy[MeSH Terms]) OR electric stimulation*[Title/Abstract]) OR nerve stimulation*[Title/Abstract]) OR Neuromodulation*) OR neurostimulat*[Title/Abstract])) AND ((((((((((((((URINARY INCONTINENCE[MeSH Terms]) OR FECAL INCONTINENCE[MeSH Terms]) OR urinary incontinence, urge[MeSH Terms]) OR urinary incontinence, stress[MeSH Terms])) OR incontinence[Title/Abstract]) OR incontinent[Title/Abstract]) OR Urinary Bladder Diseases[MeSH Terms]) OR bladder[Title/Abstract]) OR cystitis[Title/Abstract]) OR Urination Disorders[MeSH Terms]) OR Urination Disorder*[Title/Abstract]) OR “Pelvic Pain”[Mesh:noexp]) OR pelvic pain[Title/Abstract])) AND (((SACRUM[MeSH Terms]) OR sacrum[Title/Abstract]) OR sacral[Title/Abstract])) AND ((Case Reports[ptyp] OR Comment[sb] OR Editorial[ptyp] OR Letter[ptyp])))) AND Animals[Mesh:noexp]) English language- 1988-2018.

Embase Session Results (18 Sep 2018)

No. Query Results
30 27 NOT 28 AND [english]/lim AND [1988–2018]/py 1212
29 27 NOT 28 1413
28 25 NOT 26 AND [animals]/lim 177
27 25 NOT 26 1590
26 25 AND ‘case report’/de 123
25 23 NOT 24 1713
24 23 AND (‘conference abstract’/it OR ‘conference paper’/it OR ‘conference review’/it OR ‘editorial’/it OR ‘letter’/it) 1261
23 7 AND 11 AND 22 2974
22 12 OR 13 OR 14 OR 15 OR 16 OR 17 OR 18 OR 19 OR 20 OR 21 411,367
21 pelvis NEAR/2 pain 13,619
20 pelvic NEAR/2 pain 17,397
19 ‘pelvic pain’/exp. OR ‘pelvic pain’ 20,112
18 ‘urination disorder’:ti,ab 46
17 ‘micturition disorder’/exp. OR ‘micturition disorder’ 143,105
16 cystitis:ti,ab 15,122
15 bladder:ti,ab 200,602
14 ‘bladder disease’/exp. OR ‘bladder disease’ 168,493
13 incontinence:ti,ab 67,242
12 ‘incontinence’/exp. OR ‘incontinence’ 107,391
11 8 OR 9 OR 10 29,033
10 sacral:ti,ab 21,699
9 sacrum:ti,ab 6670
8 ‘sacrum’/exp. OR ‘sacrum’ 12,712
7 1 OR 2 OR 3 OR 4 OR 5 OR 6 280,338
6 neurostimulat*:ti,ab 4112
5 neuromodulation 44,386
4 ‘neuromodulation’/exp. OR ‘neuromodulation’ 44,386
3 nerve NEAR/2 stimulation 70,552
2 electric NEAR/2 stimulation 7840
1 ‘electrotherapy’/exp. OR ‘electrotherapy’  

Web of Science

TS = (“electric stimulation therapy” OR electric NEAR/2 stimulation OR nerve NEAR/2 stimulation OR neuromodulation* OR neurostimulat*) AND TS = (incontinence OR incontinent OR bladder or cystitis OR “urination disorder*” OR urin* NEAR/2 disorder* OR pelvic pain) AND TS = (sacrum OR sacral))ANDLANGUAGE: (English) AND DOCUMENT TYPES: (Article).

Indexes = SCI-EXPANDED Timespan = 1988–2018.

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Mahran, A., Baaklini, G., Hassani, D. et al. Sacral neuromodulation treating chronic pelvic pain: a meta-analysis and systematic review of the literature. Int Urogynecol J 30, 1023–1035 (2019). https://doi.org/10.1007/s00192-019-03898-w

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Keywords

  • Sacral neuromodulation
  • Chronic pelvic pain
  • Visual analog scale