Skip to main content

Neuromodulation for Chronic Pelvic Pain

Abstract

Purpose of Review

Chronic pelvic pain is a heterogeneous condition that often requires multiple physician visits and various treatments prior to achieving an acceptable management strategy. Neuromodulation has been used to treat chronic pelvic pain that has failed other therapies.

Recent Findings

Numerous modalities of neuromodulation have been used to alleviate chronic pelvic pain with promising results.

Summary

Numerous modalities of neuromodulation have demonstrated efficacy in the management of pelvic pain. Further investigation is needed to elucidate the most effective treatment modality and to identify the patients who would benefit most from this therapy.

This is a preview of subscription content, access via your institution.

References

Papers of particular interest, published recently, have been highlighted as: • Of importance

  1. Baranowski AP. Chronic pelvic pain. Best Pract Res Clin Gastroenterol. 2009;23(4):593–610. https://doi.org/10.1016/j.bpg.2009.04.013.

    Article  PubMed  Google Scholar 

  2. Baranowski AP, Lee J, Price C, Hughes J. Pelvic pain: a pathway for care developed for both men and women by the British Pain Society. Br J Anaesth. 2014;112(3):452–9. https://doi.org/10.1093/bja/aet421.

    CAS  Article  PubMed  Google Scholar 

  3. Martellucci J, Naldini G, Carriero A. Sacral nerve modulation in the treatment of chronic pelvic pain. Int J Color Dis. 2012;27(7):921–6. https://doi.org/10.1007/s00384-011-1394-2.

    CAS  Article  Google Scholar 

  4. Yang CC. Neuromodulation in male chronic pelvic pain syndrome: rationale and practice. World J Urol. 2013;31(4):767–72. https://doi.org/10.1007/s00345-013-1066-7.

    Article  PubMed  PubMed Central  Google Scholar 

  5. Ahangari A. Prevalence of chronic pelvic pain among women: an updated review. Pain Physician. 2014;17(2):E141–7.

    PubMed  Google Scholar 

  6. Fariello JY, Whitmore K. Sacral neuromodulation stimulation for IC/PBS, chronic pelvic pain, and sexual dysfunction. Int Urogynecol J. 2010;21(12):1553–8. https://doi.org/10.1007/s00192-010-1281-3.

    Article  PubMed  Google Scholar 

  7. Hunter C, Dave N, Diwan S, Deer T. Neuromodulation of pelvic visceral pain: review of the literature and case series of potential novel targets for treatment. Pain Pract. 2013;13(1):3–17. https://doi.org/10.1111/j.1533-2500.2012.00558.x.

    Article  PubMed  Google Scholar 

  8. Mathias SD, Kuppermann M, Liberman RF, Lipschutz RC, Steege JF. Chronic pelvic pain: prevalence, health-related quality of life, and economic correlates. Obstet Gynecol. 1996;87(3):321–7.

    CAS  Article  PubMed  Google Scholar 

  9. Clemens JQ, Markossian T, Calhoun EA. Comparison of economic impact of chronic prostatitis/chronic pelvic pain syndrome and interstitial cystitis/painful bladder syndrome. Urology. 2009;73(4):743–6. https://doi.org/10.1016/j.urology.2008.11.007.

    Article  PubMed  PubMed Central  Google Scholar 

  10. Speer LM, Mushkbar S, Erbele T. Chronic pelvic pain in women. Am Fam Physician. 2016;93(5):380–7.

    PubMed  Google Scholar 

  11. Siegel S, Paszkiewicz E, Kirkpatrick C, Hinkel B, Oleson K. Sacral nerve stimulation in patients with chronic intractable pelvic pain. J Urol. 2001;166(5):1742–5.

    CAS  Article  PubMed  Google Scholar 

  12. Latthe P, Latthe M, Say L, Gulmezoglu M, Khan KS. WHO systematic review of prevalence of chronic pelvic pain: a neglected reproductive health morbidity. BMC Public Health. 2006;6:177. https://doi.org/10.1186/1471-2458-6-177.

    Article  PubMed  PubMed Central  Google Scholar 

  13. Everaert K, Devulder J, De Muynck M, Stockman S, Depaepe H, De Looze D, et al. The pain cycle: implications for the diagnosis and treatment of pelvic pain syndromes. Int Urogynecol J Pelvic Floor Dysfunct. 2001;12(1):9–14.

    CAS  Article  PubMed  Google Scholar 

  14. Wesselmann U. Neurogenic inflammation and chronic pelvic pain. World J Urol. 2001;19(3):180–5.

    CAS  Article  PubMed  Google Scholar 

  15. Puylaert M. Pelvic pain: mechanistically enigmatic, therapeutically challenging. Pain Pract. 2013;13(1):1–2. https://doi.org/10.1111/papr.12019.

    Article  PubMed  Google Scholar 

  16. Simis M, Reidler JS, Duarte Macea D, Moreno Duarte I, Wang X, Lenkinski R, et al. Investigation of central nervous system dysfunction in chronic pelvic pain using magnetic resonance spectroscopy and noninvasive brain stimulation. Pain Pract. 2015;15(5):423–32. https://doi.org/10.1111/papr.12202.

    Article  PubMed  Google Scholar 

  17. Melzack R, Wall PD. Pain mechanisms: a new theory. Science. 1965;150(3699):971–9.

    CAS  Article  PubMed  Google Scholar 

  18. Rushton DN. Electrical stimulation in the treatment of pain. Disabil Rehabil. 2002;24(8):407–15. https://doi.org/10.1080/09638280110108832.

    Article  PubMed  Google Scholar 

  19. Hanai F. Effect of electrical stimulation of peripheral nerves on neuropathic pain. Spine (Phila Pa 1976). 2000;25(15):1886–92.

    CAS  Article  Google Scholar 

  20. Basbaum AI, Fields HL. Endogenous pain control mechanisms: review and hypothesis. Ann Neurol. 1978;4(5):451–62. https://doi.org/10.1002/ana.410040511.

    CAS  Article  PubMed  Google Scholar 

  21. Block L. Glial dysfunction and persistent neuropathic postsurgical pain. Scand J Pain. 2016;10:74–81. https://doi.org/10.1016/j.sjpain.2015.10.002.

    PubMed  Google Scholar 

  22. Siegel SW, Catanzaro F, Dijkema HE, Elhilali MM, Fowler CJ, Gajewski JB, et al. Long-term results of a multicenter study on sacral nerve stimulation for treatment of urinary urge incontinence, urgency-frequency, and retention. Urology. 2000;56(6 Suppl 1):87–91.

    CAS  Article  PubMed  Google Scholar 

  23. Smits H, van Kleef M, Holsheimer J, Joosten EA. Experimental spinal cord stimulation and neuropathic pain: mechanism of action, technical aspects, and effectiveness. Pain Pract. 2013;13(2):154–68. https://doi.org/10.1111/j.1533-2500.2012.00579.x.

    Article  PubMed  Google Scholar 

  24. Chen R, Nickel JC. Acupuncture ameliorates symptoms in men with chronic prostatitis/chronic pelvic pain syndrome. Urology. 2003;61(6):1156–9. discussion 9

    Article  PubMed  Google Scholar 

  25. Lee SW, Liong ML, Yuen KH, Leong WS, Chee C, Cheah PY, et al. Acupuncture versus sham acupuncture for chronic prostatitis/chronic pelvic pain. Am J Med. 2008;121(1):79 e1–7. https://doi.org/10.1016/j.amjmed.2007.07.033.

    Article  Google Scholar 

  26. Kim HW, Roh DH, Yoon SY, Kang SY, Kwon YB, Han HJ, et al. The anti-inflammatory effects of low- and high-frequency electroacupuncture are mediated by peripheral opioids in a mouse air pouch inflammation model. J Altern Complement Med. 2006;12(1):39–44. https://doi.org/10.1089/acm.2006.12.39.

    CAS  Article  PubMed  Google Scholar 

  27. Lee SH, Lee BC. Electroacupuncture relieves pain in men with chronic prostatitis/chronic pelvic pain syndrome: three-arm randomized trial. Urology. 2009;73(5):1036–41. https://doi.org/10.1016/j.urology.2008.10.047.

    Article  PubMed  Google Scholar 

  28. Fall M, Oberpenning F, Peeker R. Treatment of bladder pain syndrome/interstitial cystitis 2008: can we make evidence-based decisions? Eur Urol. 2008;54(1):65–75. https://doi.org/10.1016/j.eururo.2008.03.086.

    Article  PubMed  Google Scholar 

  29. Sonmez MG, Kozanhan B. Complete response to acupuncture therapy in female patients with refractory interstitial cystitis/bladder pain syndrome. Ginekol Pol. 2017;88(2):61–7. https://doi.org/10.5603/GP.a2017.0013.

    Article  PubMed  Google Scholar 

  30. Rowe E, Smith C, Laverick L, Elkabir J, Witherow RO, Patel A. A prospective, randomized, placebo controlled, double-blind study of pelvic electromagnetic therapy for the treatment of chronic pelvic pain syndrome with 1 year of followup. J Urol. 2005;173(6):2044–7. https://doi.org/10.1097/01.ju.0000158445.68149.38.

    CAS  Article  PubMed  Google Scholar 

  31. Paick JS, Lee SC, Ku JH. More effects of extracorporeal magnetic innervation and terazosin therapy than terazosin therapy alone for non-inflammatory chronic pelvic pain syndrome: a pilot study. Prostate Cancer Prostatic Dis. 2006;9(3):261–5. https://doi.org/10.1038/sj.pcan.4500881.

    CAS  Article  PubMed  Google Scholar 

  32. Claydon LS, Chesterton LS, Barlas P, Sim J. Dose-specific effects of transcutaneous electrical nerve stimulation (TENS) on experimental pain: a systematic review. Clin J Pain. 2011;27(7):635–47. https://doi.org/10.1097/AJP.0b013e31821962b4.

    Article  PubMed  Google Scholar 

  33. Sikiru L, Shmaila H, Muhammed SA. Transcutaneous electrical nerve stimulation (TENS) in the symptomatic management of chronic prostatitis/chronic pelvic pain syndrome: a placebo-control randomized trial. Int Braz J Urol. 2008;34(6):708–13. discussion 14

    Article  PubMed  Google Scholar 

  34. Schneider MP, Tellenbach M, Mordasini L, Thalmann GN, Kessler TM. Refractory chronic pelvic pain syndrome in men: can transcutaneous electrical nerve stimulation help? BJU Int. 2013;112(2):E159–63. https://doi.org/10.1111/bju.12005.

    Article  PubMed  Google Scholar 

  35. Weitz SH, Tunick PA, McElhinney L, Mitchell T, Kronzon I. Pseudoatrial flutter: artifact simulating atrial flutter caused by a transcutaneous electrical nerve stimulator (TENS). Pacing Clin Electrophysiol. 1997;20(12 Pt 1):3010–1.

    CAS  Article  PubMed  Google Scholar 

  36. Biemans JM, van Balken MR. Efficacy and effectiveness of percutaneous tibial nerve stimulation in the treatment of pelvic organ disorders: a systematic review. Neuromodulation. 2013;16(1):25–33. https://doi.org/10.1111/j.1525-1403.2012.00504.x.

    Article  PubMed  Google Scholar 

  37. Staskin DR, Peters KM, MacDiarmid S, Shore N, de Groat WC. Percutaneous tibial nerve stimulation: a clinically and cost effective addition to the overactive bladder algorithm of care. Curr Urol Rep. 2012;13(5):327–34. https://doi.org/10.1007/s11934-012-0274-9.

    Article  PubMed  PubMed Central  Google Scholar 

  38. Tirlapur SA, Vlismas A, Ball E, Khan KS. Nerve stimulation for chronic pelvic pain and bladder pain syndrome: a systematic review. Acta Obstet Gynecol Scand. 2013;92(8):881–7. https://doi.org/10.1111/aogs.12184.

    Article  PubMed  Google Scholar 

  39. Kabay S, Kabay SC, Yucel M, Ozden H. Efficiency of posterior tibial nerve stimulation in category IIIB chronic prostatitis/chronic pelvic pain: a Sham-Controlled Comparative Study. Urol Int. 2009;83(1):33–8. https://doi.org/10.1159/000224865.

    Article  PubMed  Google Scholar 

  40. O’Reilly BA, Dwyer PL, Hawthorne G, Cleaver S, Thomas E, Rosamilia A, et al. Transdermal posterior tibial nerve laser therapy is not effective in women with interstitial cystitis. J Urol. 2004;172(5 Pt 1):1880–3.

    Article  PubMed  Google Scholar 

  41. van Balken MR, Vandoninck V, Messelink BJ, Vergunst H, Heesakkers JP, Debruyne FM, et al. Percutaneous tibial nerve stimulation as neuromodulative treatment of chronic pelvic pain. Eur Urol. 2003;43(2):158–63. discussion 63

    Article  PubMed  Google Scholar 

  42. Gokyildiz S, Kizilkaya Beji N, Yalcin O, Istek A. Effects of percutaneous tibial nerve stimulation therapy on chronic pelvic pain. Gynecol Obstet Investig. 2012;73(2):99–105. https://doi.org/10.1159/000328447.

    Article  Google Scholar 

  43. Ragab MM, Tawfik AM, Abo El-enen M, Elnady M, El-Gamal OM, El-Kordy M, et al. Evaluation of percutaneous tibial nerve stimulation for treatment of refractory painful bladder syndrome. Urology. 2015;86(4):707–11. https://doi.org/10.1016/j.urology.2015.06.041.

    Article  PubMed  Google Scholar 

  44. Zhao J, Bai J, Zhou Y, Qi G, Du L. Posterior tibial nerve stimulation twice a week in patients with interstitial cystitis. Urology. 2008;71(6):1080–4. https://doi.org/10.1016/j.urology.2008.01.018.

    Article  PubMed  Google Scholar 

  45. Maher CF, Carey MP, Dwyer PL, Schluter PL. Percutaneous sacral nerve root neuromodulation for intractable interstitial cystitis. J Urol. 2001;165(3):884–6.

    CAS  Article  PubMed  Google Scholar 

  46. Shaker H, Hassouna MM. Sacral root neuromodulation in the treatment of various voiding and storage problems. Int Urogynecol J Pelvic Floor Dysfunct. 1999;10(5):336–43.

    CAS  Article  PubMed  Google Scholar 

  47. • Siegel S, Noblett K, Mangel J, Bennett J, Griebling TL, Sutherland SE et al. Five-year followup results of a prospective, multicenter study in overactive bladder subjects treated with sacral neuromodulation. J Urol 2017. doi:https://doi.org/10.1016/j.juro.2017.07.010. Demonstrated sustained improvement in OAB and pelvic pain symptoms at 5-year follow-up.

  48. Giannantoni A, Bini V, Dmochowski R, Hanno P, Nickel JC, Proietti S, et al. Contemporary management of the painful bladder: a systematic review. Eur Urol. 2012;61(1):29–53. https://doi.org/10.1016/j.eururo.2011.07.069.

    Article  PubMed  Google Scholar 

  49. Marcelissen TA, Leong RK, Serroyen J, van Kerrebroeck PE, De Wachter SG. The use of bilateral sacral nerve stimulation in patients with loss of unilateral treatment efficacy. J Urol. 2011;185(3):976–80. https://doi.org/10.1016/j.juro.2010.10.065.

    Article  PubMed  Google Scholar 

  50. Alonso Guardo L, Cano Gala C, Sanchez Poveda D, Rueda Juan P, Sanchez Montero FJ, Garzon Sanchez JC, et al. Caudal neuromodulation with the transforaminal sacral electrode (InterStim(R)): experience in a pain center regarding 12 implants. Korean J Pain. 2016;29(1):23–8. https://doi.org/10.3344/kjp.2016.29.1.23.

    Article  PubMed  PubMed Central  Google Scholar 

  51. Chai TC, Zhang C, Warren JW, Keay S. Percutaneous sacral third nerve root neurostimulation improves symptoms and normalizes urinary HB-EGF levels and antiproliferative activity in patients with interstitial cystitis. Urology. 2000;55(5):643–6.

    CAS  Article  PubMed  Google Scholar 

  52. Everaert K, Plancke H, Lefevere F, Oosterlinck W. The urodynamic evaluation of neuromodulation in patients with voiding dysfunction. Br J Urol. 1997;79(5):702–7.

    CAS  Article  PubMed  Google Scholar 

  53. Lavonius M, Suvitie P, Varpe P, Huhtinen H. Sacral neuromodulation: foray into chronic pelvic pain in end stage endometriosis. Case Rep Neurol Med. 2017;2017:2197831–4. https://doi.org/10.1155/2017/2197831.

    PubMed  PubMed Central  Google Scholar 

  54. Sokal P, Zielinski P, Harat M. Sacral roots stimulation in chronic pelvic pain. Neurol Neurochir Pol. 2015;49(5):307–12. https://doi.org/10.1016/j.pjnns.2015.07.003.

    PubMed  Google Scholar 

  55. Gajewski JB, Al-Zahrani AA. The long-term efficacy of sacral neuromodulation in the management of intractable cases of bladder pain syndrome: 14 years of experience in one centre. BJU Int. 2011;107(8):1258–64. https://doi.org/10.1111/j.1464-410X.2010.09697.x.

    Article  PubMed  Google Scholar 

  56. Marinkovic SP, Gillen LM, Marinkovic CM. Minimum 6-year outcomes for interstitial cystitis treated with sacral neuromodulation. Int Urogynecol J. 2011;22(4):407–12. https://doi.org/10.1007/s00192-010-1235-9.

    Article  PubMed  Google Scholar 

  57. Powell CR, Kreder KJ. Long-term outcomes of urgency-frequency syndrome due to painful bladder syndrome treated with sacral neuromodulation and analysis of failures. J Urol. 2010;183(1):173–6. https://doi.org/10.1016/j.juro.2009.08.142.

    Article  PubMed  Google Scholar 

  58. Peters KM, Konstandt D. Sacral neuromodulation decreases narcotic requirements in refractory interstitial cystitis. BJU Int. 2004;93(6):777–9. https://doi.org/10.1111/j.1464-410X.2003.04745.x.

    CAS  Article  PubMed  Google Scholar 

  59. Bade J. Long-term efficacy of sacral neuromodulation (Interstim) in patients with refractory interstitis cystisis (IC) shows tendency to decrease. J Urol, suppl. 2006;175:98.

    Article  Google Scholar 

  60. Berman C. Poor results using sacral nerve stimulation (Interstim) for treating pelvic pain patients. J Urol, suppl. 2003;169:94.

    Google Scholar 

  61. Laviana A, Jellison F, Kim JH. Sacral neuromodulation for refractory overactive bladder, interstitial cystitis, and painful bladder syndrome. Neurosurg Clin N Am. 2014;25(1):33–46. https://doi.org/10.1016/j.nec.2013.08.001.

    Article  PubMed  Google Scholar 

  62. Peters KM, Feber KM, Bennett RC. Sacral versus pudendal nerve stimulation for voiding dysfunction: a prospective, single-blinded, randomized, crossover trial. Neurourol Urodyn. 2005;24(7):643–7. https://doi.org/10.1002/nau.20174.

    Article  PubMed  Google Scholar 

  63. Sherman ND, Amundsen CL. Current and future techniques of neuromodulation for bladder dysfunction. Curr Urol Rep. 2007;8(6):448–54.

    Article  PubMed  Google Scholar 

  64. Peters KM, Feber KM, Bennett RC. A prospective, single-blind, randomized crossover trial of sacral vs pudendal nerve stimulation for interstitial cystitis. BJU Int. 2007;100(4):835–9. https://doi.org/10.1111/j.1464-410X.2007.07082.x.

    Article  PubMed  Google Scholar 

  65. • Fan AKK, Peters KM, Buora J. Neuromodulation for chronic urogenital pain: a comparison of pudendal and sacral nerve stimulation. J Urol Suppl. 2017;197:e1046–e7. Their data suggest that pudendal nerve stimulation may be effective in those who have failed sacral neuromodulation.

    Article  Google Scholar 

  66. Offiah I, McMahon SB, O'Reilly BA. Interstitial cystitis/bladder pain syndrome: diagnosis and management. Int Urogynecol J. 2013;24(8):1243–56. https://doi.org/10.1007/s00192-013-2057-3.

    CAS  Article  PubMed  Google Scholar 

  67. Kemler MA, de Vet HC, Barendse GA, van den Wildenberg FA, van Kleef M. Effect of spinal cord stimulation for chronic complex regional pain syndrome Type I: five-year final follow-up of patients in a randomized controlled trial. J Neurosurg. 2008;108(2):292–8. https://doi.org/10.3171/JNS/2008/108/2/0292.

    Article  PubMed  Google Scholar 

  68. Kapural L, Narouze SN, Janicki TI, Mekhail N. Spinal cord stimulation is an effective treatment for the chronic intractable visceral pelvic pain. Pain Med. 2006;7(5):440–3. https://doi.org/10.1111/j.1526-4637.2006.00165.x.

    Article  PubMed  Google Scholar 

  69. Schu S, Gulve A, ElDabe S, Baranidharan G, Wolf K, Demmel W, et al. Spinal cord stimulation of the dorsal root ganglion for groin pain-a retrospective review. Pain Pract. 2015;15(4):293–9. https://doi.org/10.1111/papr.12194.

    Article  PubMed  Google Scholar 

  70. Buffenoir K, Rioult B, Hamel O, Labat JJ, Riant T, Robert R. Spinal cord stimulation of the conus medullaris for refractory pudendal neuralgia: a prospective study of 27 consecutive cases. Neurourol Urodyn. 2015;34(2):177–82. https://doi.org/10.1002/nau.22525.

    Article  PubMed  Google Scholar 

  71. Louppe JM, Nguyen JP, Robert R, Buffenoir K, de Chauvigny E, Riant T, et al. Motor cortex stimulation in refractory pelvic and perineal pain: report of two successful cases. Neurourol Urodyn. 2013;32(1):53–7. https://doi.org/10.1002/nau.22269.

    Article  PubMed  Google Scholar 

  72. Landau B, Levy RM. Neuromodulation techniques for medically refractory chronic pain. Annu Rev Med. 1993;44:279–87. https://doi.org/10.1146/annurev.me.44.020193.001431.

    CAS  Article  PubMed  Google Scholar 

  73. Velasco F, Arguelles C, Carrillo-Ruiz JD, Castro G, Velasco AL, Jimenez F, et al. Efficacy of motor cortex stimulation in the treatment of neuropathic pain: a randomized double-blind trial. J Neurosurg. 2008;108(4):698–706. https://doi.org/10.3171/JNS/2008/108/4/0698.

    Article  PubMed  Google Scholar 

  74. Fenton BW, Palmieri PA, Boggio P, Fanning J, Fregni F. A preliminary study of transcranial direct current stimulation for the treatment of refractory chronic pelvic pain. Brain Stimul. 2009;2(2):103–7. https://doi.org/10.1016/j.brs.2008.09.009.

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Justina Tam.

Ethics declarations

Conflict of Interest

Justina Tam, Charles Loeb, Daniel Grajower, Jason Kim, and Steven Weissbart each declare no potential conflicts of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

Additional information

This article is part of the Topical Collection on Female Urology

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Tam, J., Loeb, C., Grajower, D. et al. Neuromodulation for Chronic Pelvic Pain. Curr Urol Rep 19, 32 (2018). https://doi.org/10.1007/s11934-018-0783-2

Download citation

  • Published:

  • DOI: https://doi.org/10.1007/s11934-018-0783-2

Keywords

  • Chronic pelvic pain
  • Neuromodulation
  • PTNS
  • Sacral neuromodulation
  • Pudendal nerve stimulation
  • TENS