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

  • Original Article
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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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Authors and Affiliations

  1. Division of Female Pelvic Medicine and Reconstructive Surgery, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Mailstop MAC 5034, Cleveland, OH, 44106, USA

    Amr Mahran, Adonis K. Hijaz, Sangeeta T. Mahajan & Sherif A. El-Nashar

  2. Urology Institute, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA

    Amr Mahran, Gina Baaklini & Adonis K. Hijaz

  3. Department of Urology, Assiut University, Assiut, Egypt

    Amr Mahran, Hassan A. Abolella & Ahmed S. Safwat

  4. Department of Obstetrics and Gynecology, Assiut University, Assiut, Egypt

    Daisy Hassani & Sherif A. El-Nashar

  5. Core Library, University Hospitals Cleveland Medical Center, Cleveland, OH, USA

    Mandy Neudecker

  6. MetroUrology, Minneapolis, MN, USA

    Steven W. Siegel

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  1. Amr Mahran
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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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