Neuromodulation for Chronic Pelvic Pain

  • Jessica C. Lloyd
  • Courtenay K. MooreEmail author


Chronic pelvic pain, a complex condition defined by non-malignant pain of the pelvic musculature or viscera often with associated hyperalgesia, is difficult to treat. The pathophysiology can be hard to delineate, as pelvic innervation involves the sympathetic, parasympathetic, and somatic nervous systems. However, dysregulated central nervous system responses to non-noxious stimuli are likely the major underlying factor.

Given this proposed etiology, some clinicians offer sacral neuromodulation as part of a multimodal approach to this condition, believing that neuromodulation can restore the balance between excitatory and inhibitory impulses to and from the pelvic organs at the levels of the sacral and suprasacral spinal cord. Studies have demonstrated improvement in pain in some patients, though these are mostly small and non-randomized, making generalization difficult. Controversy remains regarding the best approach, including which pelvic nerves to target and whether bilateral stimulation offers better results than unilateral stimulation. Large-scale randomized trials with long term follow up and clearly stated, strict inclusion criteria are needed in order to more thoroughly evaluate SNS as a treatment for chronic pelvic pain.


Sacral neuromodulation Chronic pelvic pain Pelvic floor dysfunction Interstitial cystitis Painful bladder syndrome Posterior tibial nerve stimulation Pudendal nerve stimulation Sacral nerve stimulation S3 sacral nerve Gate theory Hyperalgesia 


  1. 1.
    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.CrossRefPubMedGoogle Scholar
  2. 2.
    Kothari S. Neuromodulatory approaches to chronic pelvic pain and coccygodynia. Acta Neurochir Suppl. 2007;97(Pt 1):365–71.PubMedGoogle Scholar
  3. 3.
    Fariello JY, Whitmore K. Sacral neuromodulation stimulation for IC/PBS, chronic pelvic pain, and sexual dysfunction. Int Urogynecol J. 2010;21(12):1553–8.CrossRefPubMedGoogle Scholar
  4. 4.
    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.CrossRefPubMedGoogle Scholar
  5. 5.
    Lampe A, Solder E, Ennemoser A, Schubert C, Rumpold G, Sollner W. Chronic pelvic pain and previous sexual abuse. Obstet Gynecol. 2000;96(6):929–33.PubMedGoogle Scholar
  6. 6.
    Heim C, Ehlert U, Hanker JP, Hellhammer DH. Abuse-related posttraumatic stress disorder and alterations of the hypothalamic-pituitary-adrenal axis in women with chronic pelvic pain. Psychosom Med. 1998;60(3):309–18.CrossRefPubMedGoogle Scholar
  7. 7.
    Martinez-Lavin M. Is fibromyalgia a generalized reflex sympathetic dystrophy? Clin Exp Rheumatol. 2001;19(1):1–3.PubMedGoogle Scholar
  8. 8.
    Longstreth GF. Irritable bowel syndrome and chronic pelvic pain. Obstet Gynecol Surv. 1994;49(7):505–7.CrossRefPubMedGoogle Scholar
  9. 9.
    de la Rosette JJ, Hubregtse MR, Meuleman EJ, Stolk-Engelaar MV, Debruyne FM. Diagnosis and treatment of 409 patients with prostatitis syndromes. Urology. 1993;41(4):301–7.CrossRefPubMedGoogle Scholar
  10. 10.
    Krieger JN, Nyberg L Jr, Nickel JC. NIH consensus definition and classification of prostatitis. JAMA. 1999;282(3):236–7.CrossRefPubMedGoogle Scholar
  11. 11.
    Raj P. Practical management of pain. St. Louis, MO: Mosby Inc.; 2000.Google Scholar
  12. 12.
    Janicki TI. Chronic pelvic pain as a form of complex regional pain syndrome. Clin Obstet Gynecol. 2003;46(4):797–803.CrossRefPubMedGoogle Scholar
  13. 13.
    Comiter CV. Sacral neuromodulation for the symptomatic treatment of refractory interstitial cystitis: a prospective study. J Urol. 2003;169(4):1369–73.CrossRefPubMedGoogle Scholar
  14. 14.
    Prevalence of interstitial cystitis/painful bladder syndrome in the United States: The RAND Interstitial Cystitis Epidemiology study. Annual Meeting of the American Urological Association; 2009.Google Scholar
  15. 15.
    Nazif O, Teichman JM, Gebhart GF. Neural upregulation in interstitial cystitis. Urology. 2007;69(4 Suppl):24–33.CrossRefPubMedGoogle Scholar
  16. 16.
    Hanno P, Burks D, Clemens J, Dmochowski R, Erickson D, et al. Diagnosis and Treatment of Interstitial Cystitis/Bladder Pain Syndrome. 2014. Accessed 11 Nov 2016.
  17. 17.
    Carrico DJ, Peters KM, Diokno AC. Guided imagery for women with interstitial cystitis: results of a prospective, randomized controlled pilot study. J Altern Complement Med. 2008;14(1):53–60.CrossRefPubMedGoogle Scholar
  18. 18.
    Foster HE Jr, Hanno PM, Nickel JC, Payne CK, Mayer RD, Burks DA, et al. Effect of amitriptyline on symptoms in treatment naive patients with interstitial cystitis/painful bladder syndrome. J Urol. 2010;183(5):1853–8.CrossRefPubMedPubMedCentralGoogle Scholar
  19. 19.
    Hsieh TF, KJ Y, Lin SY. Possible application of Raman microspectroscopy to verify the interstitial cystitis diagnosis after potassium sensitivity test: phenylalanine or tryptophan as a biomarker. Dis Markers. 2007;23(3):147–52.CrossRefPubMedPubMedCentralGoogle Scholar
  20. 20.
    Herati AS, Shorter B, Srinivasan AK, Tai J, Seideman C, Lesser M, et al. Effects of foods and beverages on the symptoms of chronic prostatitis/chronic pelvic pain syndrome. Urology. 2013;82(6):1376–80.CrossRefPubMedGoogle Scholar
  21. 21.
    Peters KM, Carrico DJ, Kalinowski SE, Ibrahim IA, Diokno AC. Prevalence of pelvic floor dysfunction in patients with interstitial cystitis. Urology. 2007;70(1):16–8.CrossRefPubMedGoogle Scholar
  22. 22.
    Weiss JM. Pelvic floor myofascial trigger points: manual therapy for interstitial cystitis and the urgency-frequency syndrome. J Urol. 2001;166(6):2226–31.CrossRefPubMedGoogle Scholar
  23. 23.
    Anderson RU, Wise D, Sawyer T, Chan C. Integration of myofascial trigger point release and paradoxical relaxation training treatment of chronic pelvic pain in men. J Urol. 2005;174(1):155–60.CrossRefPubMedGoogle Scholar
  24. 24.
    FitzGerald MP, Anderson RU, Potts J, Payne CK, Peters KM, Clemens JQ, et al. Randomized multicenter feasibility trial of myofascial physical therapy for the treatment of urological chronic pelvic pain syndromes. J Urol. 2009;182(2):570–80.CrossRefPubMedPubMedCentralGoogle Scholar
  25. 25.
    FitzGerald MP, Payne CK, Lukacz ES, Yang CC, Peters KM, Chai TC, et al. Randomized multicenter clinical trial of myofascial physical therapy in women with interstitial cystitis/painful bladder syndrome and pelvic floor tenderness. J Urol. 2012;187(6):2113–8.CrossRefPubMedPubMedCentralGoogle Scholar
  26. 26.
    van Ophoven A, Pokupic S, Heinecke A, Hertle L. A prospective, randomized, placebo controlled, double-blind study of amitriptyline for the treatment of interstitial cystitis. J Urol. 2004;172(2):533–6.CrossRefPubMedGoogle Scholar
  27. 27.
    Thilagarajah R, Witherow RO, Walker MM. Oral cimetidine gives effective symptom relief in painful bladder disease: a prospective, randomized, double-blind placebo-controlled trial. BJU Int. 2001;87(3):207–12.CrossRefPubMedGoogle Scholar
  28. 28.
    Dasgupta P, Sharma SD, Womack C, Blackford HN, Dennis P. Cimetidine in painful bladder syndrome: a histopathological study. BJU Int. 2001;88(3):183–6.CrossRefPubMedGoogle Scholar
  29. 29.
    Seshadri P, Emerson L, Morales A. Cimetidine in the treatment of interstitial cystitis. Urology. 1994;44(4):614–6.CrossRefPubMedGoogle Scholar
  30. 30.
    Theoharides TC, Sant GR. Hydroxyzine therapy for interstitial cystitis. Urology. 1997;49(5A Suppl):108–10.CrossRefPubMedGoogle Scholar
  31. 31.
    Sant GR, Propert KJ, Hanno PM, Burks D, Culkin D, Diokno AC, et al. A pilot clinical trial of oral pentosan polysulfate and oral hydroxyzine in patients with interstitial cystitis. J Urol. 2003;170(3):810–5.CrossRefPubMedGoogle Scholar
  32. 32.
    Theoharides TC. Hydroxyzine in the treatment of interstitial cystitis. Urol Clin North Am. 1994;21(1):113–9.PubMedGoogle Scholar
  33. 33.
    Colaco MA, Evans RJ. Current recommendations for bladder instillation therapy in the treatment of interstitial cystitis/bladder pain syndrome. Curr Urol Rep. 2013;14(5):442–7.CrossRefPubMedGoogle Scholar
  34. 34.
    Nickel JC, Jain P, Shore N, Anderson J, Giesing D, Lee H, et al. Continuous intravesical lidocaine treatment for interstitial cystitis/bladder pain syndrome: safety and efficacy of a new drug delivery device. Sci Transl Med. 2012;4(143):143ra100.CrossRefPubMedGoogle Scholar
  35. 35.
    Cole EE, Scarpero HM, Dmochowski RR. Are patient symptoms predictive of the diagnostic and/or therapeutic value of hydrodistention? Neurourol Urodyn. 2005;24(7):638–42.CrossRefPubMedGoogle Scholar
  36. 36.
    Erickson DR, Kunselman AR, Bentley CM, Peters KM, Rovner ES, Demers LM, et al. Changes in urine markers and symptoms after bladder distention for interstitial cystitis. J Urol. 2007;177(2):556–60.CrossRefPubMedPubMedCentralGoogle Scholar
  37. 37.
    Ottem DP, Teichman JM. What is the value of cystoscopy with hydrodistension for interstitial cystitis? Urology. 2005;66(3):494–9.CrossRefPubMedGoogle Scholar
  38. 38.
    Kuo HC, Chancellor MB. Comparison of intravesical botulinum toxin type A injections plus hydrodistention with hydrodistention alone for the treatment of refractory interstitial cystitis/painful bladder syndrome. BJU Int. 2009;104(5):657–61.CrossRefPubMedGoogle Scholar
  39. 39.
    Pinto R, Lopes T, Frias B, Silva A, Silva JA, Silva CM, et al. Trigonal injection of botulinum toxin A in patients with refractory bladder pain syndrome/interstitial cystitis. Eur Urol. 2010;58(3):360–5.CrossRefPubMedGoogle Scholar
  40. 40.
    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.CrossRefPubMedGoogle Scholar
  41. 41.
    Ghazwani YQ, Elkelini MS, Hassouna MM. Efficacy of sacral neuromodulation in treatment of bladder pain syndrome: long-term follow-up. Neurourol Urodyn. 2011;30(7):1271–5.PubMedGoogle Scholar
  42. 42.
    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.CrossRefPubMedGoogle Scholar
  43. 43.
    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.CrossRefPubMedGoogle Scholar
  44. 44.
    Sairanen J, Tammela TL, Leppilahti M, Multanen M, Paananen I, Lehtoranta K, et al. Cyclosporine A and pentosan polysulfate sodium for the treatment of interstitial cystitis: a randomized comparative study. J Urol. 2005;174(6):2235–8.CrossRefPubMedGoogle Scholar
  45. 45.
    Forrest JB, Payne CK, Erickson DR. Cyclosporine A for refractory interstitial cystitis/bladder pain syndrome: experience of 3 tertiary centers. J Urol. 2012;188(4):1186–91.CrossRefPubMedGoogle Scholar
  46. 46.
    Rossberger J, Fall M, Jonsson O, Peeker R. Long-term results of reconstructive surgery in patients with bladder pain syndrome/interstitial cystitis: subtyping is imperative. Urology. 2007;70(4):638–42.CrossRefPubMedGoogle Scholar
  47. 47.
    Madersbacher H. Conservative therapy of neurogenic disorders of micturition. Urologe A. 1999;38(1):24–9.CrossRefPubMedGoogle Scholar
  48. 48.
    Nashold BS Jr, Friedman H, Boyarsky S. Electrical activation of micturition by spinal cord stimulation. J Surg Res. 1971;11(3):144–7.CrossRefPubMedGoogle Scholar
  49. 49.
    Van Kerrebroeck PE. Advances in the role of sacral nerve neuromodulation in lower urinary tract symptoms. Int Urogynecol J. 2010;21(Suppl 2):S467–74.CrossRefPubMedGoogle Scholar
  50. 50.
    Mayer R, Howard F. Sacral nerve stimultation: neuromodulation for voiding dysfunction and pain. Neurotherapeutics. 2008;5:107–13.CrossRefPubMedPubMedCentralGoogle Scholar
  51. 51.
    Dasgupta R, Critchley HD, Dolan RJ, Fowler CJ. Changes in brain activity following sacral neuromodulation for urinary retention. J Urol. 2005;174(6):2268–72.CrossRefPubMedGoogle Scholar
  52. 52.
    Zabihi N, Mourtzinos A, Maher MG, Raz S, Rodriguez LV. Short-term results of bilateral S2-S4 sacral neuromodulation for the treatment of refractory interstitial cystitis, painful bladder syndrome, and chronic pelvic pain. Int Urogynecol J Pelvic Floor Dysfunct. 2008;19(4):553–7.CrossRefPubMedGoogle Scholar
  53. 53.
    Fall M, Baranowski AP, Elneil S, Engeler D, Hughes J, Messelink EJ, et al. EAU guidelines on chronic pelvic pain. Eur Urol. 2010;57(1):35–48.CrossRefPubMedGoogle Scholar
  54. 54.
    Melzack R, Wall P. Pain mechanisms: a new theory. Science. 1965;150:971.CrossRefGoogle Scholar
  55. 55.
    van der Pal F, Heesakkers JP, Bemelmans BL. Current opinion on the working mechanisms of neuromodulation in the treatment of lower urinary tract dysfunction. Curr Opin Urol. 2006;16(4):261–7.CrossRefPubMedGoogle Scholar
  56. 56.
    Marcelissen T, Jacobs R, van Kerrebroeck P, de Wachter S. Sacral neuromodulation as a treatment for chronic pelvic pain. J Urol. 2011;186(2):387–93.CrossRefGoogle Scholar
  57. 57.
    Hohenfellner M, Dahms SE, Matzel K, Thuroff JW. Sacral neuromodulation for treatment of lower urinary tract dysfunction. BJU Int. 2000;85(Suppl 3):10–9; discussion 22–3.CrossRefPubMedGoogle Scholar
  58. 58.
    Maher CF, Carey MP, Dwyer PL, Schluter PL. Percutaneous sacral nerve root neuromodulation for intractable interstitial cystitis. J Urol. 2001;165(3):884–6.CrossRefPubMedGoogle Scholar
  59. 59.
    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.CrossRefPubMedGoogle Scholar
  60. 60.
    Brookoff D, Bennett D. Neuromodulation in intractable interstitial cystitis and related pain syndromes. Pain Med. 2006;7(suppl 1):S166–84.CrossRefGoogle Scholar
  61. 61.
    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.CrossRefPubMedGoogle Scholar
  62. 62.
    Whitmore KE, Payne CK, Diokno AC, Lukban JC. Sacral neuromodulation in patients with interstitial cystitis: a multicenter clinical trial. Int Urogynecol J Pelvic Floor Dysfunct. 2003;14(5):305–8; discussion 308–9.CrossRefPubMedGoogle Scholar
  63. 63.
    Peters KM, Konstandt D. Sacral neuromodulation decreases narcotic requirements in refractory interstitial cystitis. BJU Int. 2004;93(6):777–9.CrossRefPubMedGoogle Scholar
  64. 64.
    Rackley R, Vasavada S, Daneshgari F. Neuromodulation for interstitial cystitis. Cleveland Clinic Glickman Urologic Institute. 2005.
  65. 65.
    Steinberg AC, Oyama IA, Whitmore KE. Bilateral S3 stimulator in patients with interstitial cystitis. Urology. 2007;69(3):441–3.CrossRefPubMedGoogle Scholar
  66. 66.
    Kim SW, Paick JS, Ku JH. Percutaneous posterior tibial nerve stimulation in patients with chronic pelvic pain: a preliminary study. Urol Int. 2007;78(1):58–62.CrossRefPubMedGoogle Scholar
  67. 67.
    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 163.CrossRefPubMedGoogle Scholar
  68. 68.
    Peters KM, Killinger KA, Boguslawski BM, Boura JA. Chronic pudendal neuromodulation: expanding available treatment options for refractory urologic symptoms. Neurourol Urodyn. 2010;29(7):1267–71.CrossRefPubMedGoogle Scholar
  69. 69.
    Heinze K, Hoermann R, Fritsch H, Dermietzel R, van Ophoven A. Comparative pilot study of implantation techniques for pudendal neuromodulation: technical and clinical outcome in first 20 patients with chronic pelvic pain. World J Urol. 2015;33(2):289–94.CrossRefPubMedGoogle Scholar
  70. 70.
    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.CrossRefPubMedGoogle Scholar

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© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Glickman Urological Institute, Cleveland ClinicClevelandUSA

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