Good long-term results of sacral neuromodulation for endometriosis related chronic pelvic pain

Good long-term results of sacral neuromodulation for endometriosis related chronic pelvic pain | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Good long-term results of sacral neuromodulation for endometriosis related chronic pelvic pain Adrian Zegrea, Emilia Ojala, Jaan Kirss jr, Pia Suvitie, Pirita Varpe, and 6 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4088264/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 07 Apr, 2025 Read the published version in BMC Women's Health → Version 1 posted 4 You are reading this latest preprint version Abstract Background Sacral neuromodulation (SNM) is an established therapy in urology and gastroenterological surgery for treatment of overactive bladder symptoms, urge urinary incontinence or fecal incontinence. SNM has also been used with good results in patients with chronic pelvic pain (CPP). Our aim was to analyze long-term results of SNM in Finnish patients with endometriosis related CPP. Methods This is a register-based retrospective study including all the endometriosis patients treated with SNM for CPP in Finland between 2004 and 2017. There were four centers where these procedures were performed, two University Hospitals and two Central Hospitals. Long-term results were assessed by phone interview in spring 2021. Results A total of 16 women with endometriosis, with a median age of 39 (25–50) years, underwent SNM treatment for chronic pelvic pain (CPP), with the median follow-up time of 73 (48–85) months. The Implantable Pulse Generator (IPG) was implanted to 14 patients (88%). By the end of the follow-up period, 10 patients (62,5% of all patients and 71% of those who received IPG) had a functional SNM. Pain was assessed by numeral rating scale (NRS) and decreased from a median of 7.4 (3.6–10) to 2.25 (0-6.5). Conclusions SNM could be a good option in the treatment of endometriosis related chronic pelvic pain when standard therapy is not enough. endometriosis chronic pelvic pain sacral neuromodulation Figures Figure 1 Figure 2 Introduction Sacral neuromodulation (SNM) is mostly used in urology to improve bladder control and also in gastroenterological surgery to improve bowel control ( 1 ). Recent systematic reviews and meta-analysis show that SNM could be an effective treatment of chronic pelvic pain (CPP), significantly reducing pain and increasing patients' quality of life with immediate to long-term effects ( 2 , 3 ). CPP is a multifactorial disorder with pain originating in any of the urogynecological, gastrointestinal, pelvic musculoskeletal, or nervous systems ( 4 ). Endometriosis is an estrogen-dependent chronic inflammatory disease defined by the presence of functional endometrial tissue outside the uterine cavity. Among women who underwent laparoscopy for CPP, endometriosis is found in about 1/3 of the cases, while only 25% of women with histological confirmed endometriosis are asymptomatic ( 5 ). Endometriosis has a massive financial impact. Estimated direct medical costs for outpatient visits for chronic pelvic pain for the U.S population of women aged 18–50 years are $ 881.5 million per year ( 6 ). SNM involves the electrical stimulation of sacral nerve roots S3 or S4 with low electrical current via an electrode placed percutaneously through the sacral foramen. Patients usually undergo a temporary evaluation period, and if successful, an implantable pulse generator (IPG) is inserted. Although the mechanism of action of sacral neuromodulation (SNM) is still not fully elucidated, it seems to involve modulation of spinal cord reflexes and brain networks by peripheral afferents. Nevertheless, motor effects mediated via efferents on direct stimulation cannot be fully excluded ( 7 ). We have already indicated that SNM may be effective in the treatment of endometriosis patients with CPP ( 8 – 10 ). This is the first study reporting long-term results of SNM in patients with CPP related to endometriosis. Materials and methods All the endometriosis patients treated with SNM for CPP in Finland between 2004 and 2017 were included. There were four centers in which SNM was performed: Oulu and Turku University Hospitals, as well as Jyväskylä and Seinäjoki Central Hospitals. SNM was performed in two stages. In the evaluation stage I, a tined lead was placed in the S3 or S4 foramina with the patient in prone Jack knife position under local or general anesthesia. After a trial period of 14 days, stage II was performed. The internal pulse generator (IPG) was implanted after a successful test period, meaning at least a 50% clinical improvement of symptoms. SNM related data was collected from patient records in 2017 and was later completed with endometriosis related data in autumn 2023. Long-term results were assessed by phone questionnaire during spring 2021. Patients were asked if the SNM device was still functioning, what was the NRS pain evaluation and, alternatively, what was the cause of removal. The primary outcome was successfully sustained SNM therapy and the decrease of NRS pain score. Success was defined as having a permanent stimulator (IPG) implanted and as having a working SNM by the end of the follow-up. Secondary outcomes were failure of the treatment and postoperative morbidity. Statistical analyses were performed using SPSS Statistics version 22 for Windows (IBM Corp, Armonk, NY, USA). Summary measurements were expressed as means with standard deviations or as medians with minimum and maximum values unless otherwise stated. Continuous variables were analyzed using Student’s t-test or Mann–Whitney U-test, the latter for non-normally distributed data. Chi-square or Fisher’s exact test was used for categorical variables. Two-tailed P values were reported and a P value < 0.05 was deemed statistically significant. This study was conducted in accordance with Finnish Medical Research Act 488/199, 295/2004 and approved by the Ethics Committee of the Hospital District of Southwest Finland (ETMK: 163/1801/2015, ETMK 7/2019). Results A total of 16 women, with a median age of 39 (25–50) years, underwent SNM treatment for CPP related to endometriosis, with a median follow-up time of 73 (48–85) months. All the patients had previously undergone at least one surgery due to endometriosis, with a median of 3 ( 1 – 6 ) operations. Deep endometriosis (88%) was more frequent than superficial endometriosis (38%) and endometrioma (44%). A significant number of patients have undergone extensive surgery including hysterectomy (44%), adnexectomy (56%) and sigmoid resection or anterior resection of the rectum (44%). Baseline characteristics are presented in Table 1 . The patient flow chart is presented in Fig. 1 . The Implantable Pulse Generator (IPG) was implanted to 14 patients (88%). The majority of the patients had the SNM electrode implanted in S3 right (38%) or S4 right (38%) foramens, S3 left (19%) and S4 left (6.3%) were less commonly used. Postoperative complications were registered in five patients (31%) after Stage 1 (pain in three patients, cable dislodgement in one patient and cable snapping in one patient) and in two patients (14%) after Stage 2 (one with pain and one with infection, where IPG and electrode were replanted). By the end of the follow-up period 10 patients (62,5% of all patients and 71% of those who received IPG) had a functional SNM. Pain NRS value dropped from median 7.4 (3.6–10) before SNM to 2.25 (0-6.5) by the end of the follow-up (Fig. 2 ). Postoperative outcomes are illustrated in Table 2 . Analysis of the two groups of patients with working SNM vs. failed SNM therapy by the end of the follow up showed no statistically significant differences when the type of endometriosis, the type of surgery or the number of surgeries were taken into consideration (Table 3 ). The number of functional electrodes did not influence the final outcome. Median number ( 4 , 2 – 4 ) of functional electrodes was the same in both groups (p = 0.940). Discussion CPP is not currently an approved US Food and Drug Administration (FDA) indication for SNM. There is emerging data showing that SNM is effective in the treatment of CPP with multifactorial etiology ( 2 , 3 , 11 ). There are only a few studies showing good short-term results of SNM in the treatment of endometriosis related CPP ( 8 – 10 ), but long-term data is lacking. This Finnish national study is the first to show promising long-term results in the difficult to treat group of endometriosis patients with CPP after surgery. The long-term efficacy of SNM in our study is reflected by the fact that 71% of the patients that received the IPG had a functioning device by the end of the follow-up and this is better than the reported SNM long-term outcomes with different etiologies ( 12 ). It is also illustrated by the decrease of the pain related NRS value from a median of 7.4 (3.6–10) before SNM to 2.25 (0-6.5) by the time of follow-up. The complication rates are comparable with those reported in earlier studies ( 2 , 13 ). The overall implantation rate of 88% in our study is better than the implantation rate of 64.3% reported by a recent meta-analysis and systematic review of SNM in CPP, with a quite diverse etiology of pain ( 2 ). The implantation rate is also better than the one of 54,8% reported by another meta-analysis and systematic review of SNM in CPP ( 3 ). CPP affects women’s quality of life deeply. CPP is often associated with migraine and headache, regardless if CPP is related or not to endometriosis ( 14 ). Endometriosis and CPP was reported to negatively impact all domains of life including physical, psychological, social, sexual, education and employment ( 15 ). A large multi-center study across Europe, UK and the USA found that the total cost per woman with endometriosis per year was €9579 with the bulk of costs (€6298) being due to absence from work ( 16 ). It has been shown that as little as a 10% reduction on a pain scale is needed to improve productivity ( 17 ). All the patients in our study underwent standard medical therapy and at least one surgery for endometriosis before SNM. According to literature, surgery does not reduce pain in 20–28% of patients ( 18 ). Post-surgical hormonal therapy has been advocated to improve the effectiveness of surgery and prevent recurrences, but it has been proven to be of limited or no benefit for endometriosis in general and for deep peritoneal endometriosis in particular ( 19 ). Given the amount of non-responders to surgery and the recurrence of pain, even though there is no evident recurrence of endometriosis in 23%, there is a need for evidence-based approaches that do not require surgery or taking hormones ( 15 ). Diet, exercise, physiotherapy, acupuncture, psychotherapy could be considered ( 15 ) and this is the area where SNM might play a role. It was suggested that a major contributing factor for endometriosis-associated pain are not the ectopic growths themselves, but rather the activity from nerves that have emerged from nearby tissues to innervate the growths, which affects the activity of neurons in the spinal cord and brain ( 20 ). This could explain why SNM is effective. Our study encourages the use of SNM in endometriosis patients with CPP post-surgery, regardless of the type of endometriosis or the extent of surgery performed. This study has a few limitations. This is a retrospective study. The total number of the patients is relatively small, but on the other hand this is a comprehensive national study including all the patients that underwent SNM therapy for endometriosis-associated CPP between 2004 and 2017. More studies are definitely needed in order to standardize the role of SNM in the treatment of endometriosis patients with persisting CPP after surgery. Conclusion Endometriosis patients with chronic pelvic pain may benefit from SNM therapy after failure of standard medical and surgical therapy, regardless of the type of endometriosis or the extent of surgery performed. More studies are needed to identify which endometriosis patients benefit the most. Abbreviations SNM (sacral neuromodulation), CPP (chronic pelvic pain), IPG (implantable pulse generator), FDA (US Food and Drug Administration) Declarations Ethics approval and consent to participate: This study was conducted in accordance with Finnish Medical Research Act 488/199, 295/2004 and approved by the Ethics Committee of the Hospital District of Southwest Finland (ETMK: 163/1801/2015, ETMK 7/2019). Informed consent to participate was obtained from all of the participants in the study. Consent for publication Not applicable. Availability of data and materials The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding This study was conducted without external funding. Authors' contributions AZ : Manuscript writing, Data analysis, Project development, EO : Data collection, JK : Data collection, Project development, PS : Data collection, PV : Project development, JM - K : Data collection, revision, TR : Project development, JS : Data collection, MU : Data analysis, revision ML : Project development and supervision, TP : Project development and supervision. Acknowledgements Not applicable References StatPearls. 2021. Greig J, Mak Q, Furrer MA, Sahai A, Raison N. Sacral neuromodulation in the management of chronic pelvic pain: A systematic review and meta-analysis. Neurourol Urodyn. 2023;42(4):822-36. Epub 20230306. doi: 10.1002/nau.25167. PubMed PMID: 36877182. Mahran A, Baaklini G, Hassani D, Abolella HA, Safwat AS, Neudecker M, et al. Sacral neuromodulation treating chronic pelvic pain: a meta-analysis and systematic review of the literature. Int Urogynecol J. 2019. Epub 2019/03/16. doi: 10.1007/s00192-019-03898-w. PubMed PMID: 30874835. Grinberg K, Sela Y, Nissanholtz-Gannot R. New Insights about Chronic Pelvic Pain Syndrome (CPPS). Int J Environ Res Public Health. 2020;17(9). Epub 20200426. doi: 10.3390/ijerph17093005. PubMed PMID: 32357440; PubMed Central PMCID: PMC7246747. Triolo O, Laganà AS, Sturlese E. Chronic pelvic pain in endometriosis: an overview. J Clin Med Res. 2013;5(3):153-63. Epub 20130423. doi: 10.4021/jocmr1288w. PubMed PMID: 23671540; PubMed Central PMCID: PMC3651065. 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. doi: 10.1016/0029-7844(95)00458-0. PubMed PMID: 8598948. De Wachter S, Vaganee D, Kessler TM. Sacral Neuromodulation: Mechanism of Action. Eur Urol Focus. 2020;6(5):823-5. Epub 20200201. doi: 10.1016/j.euf.2019.11.018. PubMed PMID: 32019718. 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. Epub 2017/04/04. doi: 10.1155/2017/2197831. PubMed PMID: 28367344; PubMed Central PMCID: PMC5358435. Zegrea A, Kirss J, Pinta T, Rautio T, Varpe P, Kairaluoma M, et al. Outcomes of sacral neuromodulation for chronic pelvic pain: a Finnish national multicenter study. Tech Coloproctol. 2020;24(3):215-20. Epub 20200121. doi: 10.1007/s10151-020-02148-2. PubMed PMID: 31965400. Zegrea A, Ojala E, Suvitie P, Varpe P, Huhtinen H, Mäkelä-Kaikkonen J, et al. Sacral neuromodulation in endometriosis - A promising treatment option for chronic pelvic pain. Acta Obstet Gynecol Scand. 2023. Epub 20231009. doi: 10.1111/aogs.14690. PubMed PMID: 37814355. Bieze M, van Haaps AP, Kapural L, Li S, Ferguson K, de Vries R, et al. Spinal Cord Stimulation for Intractable Visceral Pain Originating from the Pelvic and Abdominal Region: A Narrative Review on a Possible New Indication for Patients with Therapy-Resistant Pain. J Pain Res. 2024;17:691-736. Epub 20240219. doi: 10.2147/JPR.S445616. PubMed PMID: 38405684; PubMed Central PMCID: PMC10887953. Ismail S, Chartier-Kastler E, Perrouin-Verbe MA, Rose-Dite-Modestine J, Denys P, Phé V. Long-Term Functional Outcomes of S3 Sacral Neuromodulation for the Treatment of Idiopathic Overactive Bladder. Neuromodulation. 2017;20(8):825-9. Epub 20171002. doi: 10.1111/ner.12696. PubMed PMID: 28967986. Siegel S, Noblett K, Mangel J, Bennett J, Griebling TL, Sutherland SE, et al. Five-Year Followup Results of a Prospective, Multicenter Study of Patients with Overactive Bladder Treated with Sacral Neuromodulation. J Urol. 2018;199(1):229-36. Epub 20170711. doi: 10.1016/j.juro.2017.07.010. PubMed PMID: 28709886. Karp BI, Sinaii N, Nieman LK, Silberstein SD, Stratton P. Migraine in women with chronic pelvic pain with and without endometriosis. Fertil Steril. 2011;95(3):895-9. Epub 20101210. doi: 10.1016/j.fertnstert.2010.11.037. PubMed PMID: 21145540; PubMed Central PMCID: PMC3415219. Ball E, Khan KS. Recent advances in understanding and managing chronic pelvic pain in women with special consideration to endometriosis. F1000Res. 2020;9. Epub 20200204. doi: 10.12688/f1000research.20750.1. PubMed PMID: 32089831; PubMed Central PMCID: PMC7001750. Simoens S, Dunselman G, Dirksen C, Hummelshoj L, Bokor A, Brandes I, et al. The burden of endometriosis: costs and quality of life of women with endometriosis and treated in referral centres. Hum Reprod. 2012;27(5):1292-9. Epub 20120314. doi: 10.1093/humrep/des073. PubMed PMID: 22422778. Gerlinger C, Schumacher U, Faustmann T, Colligs A, Schmitz H, Seitz C. Defining a minimal clinically important difference for endometriosis-associated pelvic pain measured on a visual analog scale: analyses of two placebo-controlled, randomized trials. Health Qual Life Outcomes. 2010;8:138. Epub 2010/11/24. doi: 10.1186/1477-7525-8-138. PubMed PMID: 21106059; PubMed Central PMCID: PMC3002916. Abbott J, Hawe J, Hunter D, Holmes M, Finn P, Garry R. Laparoscopic excision of endometriosis: a randomized, placebo-controlled trial. Fertil Steril. 2004;82(4):878-84. doi: 10.1016/j.fertnstert.2004.03.046. PubMed PMID: 15482763. Somigliana E, Busnelli A, Benaglia L, Viganò P, Leonardi M, Paffoni A, et al. Postoperative hormonal therapy after surgical excision of deep endometriosis. Eur J Obstet Gynecol Reprod Biol. 2017;209:77-80. Epub 20160401. doi: 10.1016/j.ejogrb.2016.03.030. PubMed PMID: 27067871. Stratton P, Berkley KJ. Chronic pelvic pain and endometriosis: translational evidence of the relationship and implications. Hum Reprod Update. 2011;17(3):327-46. Epub 2010/11/23. doi: 10.1093/humupd/dmq050. PubMed PMID: 21106492; PubMed Central PMCID: PMC3072022. Tables Table 1 Baseline characteristics Variable Age, median (min-max) 39 (25–50) Follow-up time, median (min-max) 73 months (48–85) G, median (min-max) 1 (0–3) P, median (min-max) 0 (0–2) Superficial endometriosis 6 (38) Deep endometriosis 14 (88) Endometrioma 7 (44) Endometrioma enucleation 7 (44) Hysterectomy 7 (44) Salpingectomy 9 (56) Ovariectomy 9 (56) Superficial peritoneal endometriosis resection 6 (38) Anterior resection of rectum or sigmoid resection 7 (44) Number of endometriosis surgeries, median (min-max) 3 ( 1 – 6 ) Light opioides 10 (63) Strong opioides 6 (38) Table 2 Postoperative SNM outcomes Variable Stage 1 test 16 (100) Stage 1 complications 5 (31) Stage 2 implantation rate 14 (88) Stage 2 complications 2 ( 14 ) Working SNM at the end of follow-up 10 (71) NRS at the end of the follow-up, median (min-max) 2.25 (0-6.5) Table 3 Comparative analysis of patients with working SNM vs. failed SNM therapy Working SNM Failed therapy p-value Age 33 (29–40) 26 (25–27) 0.562 Preoperative pain 7 (3.6–8.4) 9.5 ( 9 – 10 ) 0.095 Superficial endometriosis 2 (33) 4 (67) 0.118 Deep endometriosis 8 (57) 6 (43) 0.500 Endometrioma 6 (86) 1 ( 14 ) 0.145 Endometrioma enucleation 6 (86) 1 ( 14 ) 0.145 Hysterectomy 5 (71) 2 (29) 0.633 Salpingectomy 7 (78) 2 (22) 0.302 Ovariectomy 7 (78) 2 (22) 0.302 Superficial peritoneal endometriosis resection 2 (33) 4 (67) 0.118 Anterior resection of rectum or sigmoid resection 4 (57) 3 (43) 0.999 Number of endometriosis surgeries, median (min-max) 4 ( 1 – 6 ) 3 ( 1 – 6 ) 0.635 Light opioides 7 (70) 3 (30) 0.726 Strong opioides 4 (67) 2 (33) 0.915 Number of electrodes 4 ( 2 – 4 ) 4 ( 2 – 4 ) 0.940 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 07 Apr, 2025 Read the published version in BMC Women's Health → Version 1 posted Editorial decision: Revision requested 03 Apr, 2024 Editor assigned by journal 03 Apr, 2024 Submission checks completed at journal 14 Mar, 2024 First submitted to journal 12 Mar, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4088264","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":279722069,"identity":"3114b4cd-0ccd-4dd2-b84a-a90f3cd4e4ac","order_by":0,"name":"Adrian 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chart\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-4088264/v1/1ef0e88c45f4c45476abc510.jpeg"},{"id":52902203,"identity":"5ac9b87f-7ee0-465c-a492-9b02723404f1","added_by":"auto","created_at":"2024-03-18 14:15:12","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":145940,"visible":true,"origin":"","legend":"\u003cp\u003ePain scores (NRS) before SNM, during test-phase and at the end of the follow-up\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-4088264/v1/f9811d08f22137f18f05304e.jpeg"},{"id":80558863,"identity":"a230ae20-3459-463c-ad3f-f5d4b573ad86","added_by":"auto","created_at":"2025-04-14 16:16:44","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":856635,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4088264/v1/0a4cd24f-a405-4a43-9214-f28b2aa965b7.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Good long-term results of sacral neuromodulation for endometriosis related chronic pelvic pain","fulltext":[{"header":"Introduction","content":"\u003cp\u003eSacral neuromodulation (SNM) is mostly used in urology to improve bladder control and also in gastroenterological surgery to improve bowel control (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Recent systematic reviews and meta-analysis show that SNM could be an effective treatment of chronic pelvic pain (CPP), significantly reducing pain and increasing patients' quality of life with immediate to long-term effects (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eCPP is a multifactorial disorder with pain originating in any of the urogynecological, gastrointestinal, pelvic musculoskeletal, or nervous systems (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Endometriosis is an estrogen-dependent chronic inflammatory disease defined by the presence of functional endometrial tissue outside the uterine cavity. Among women who underwent laparoscopy for CPP, endometriosis is found in about 1/3 of the cases, while only 25% of women with histological confirmed endometriosis are asymptomatic (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Endometriosis has a massive financial impact. Estimated direct medical costs for outpatient visits for chronic pelvic pain for the U.S population of women aged 18\u0026ndash;50 years are \u003cspan\u003e$\u003c/span\u003e881.5\u0026nbsp;million per year (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eSNM involves the electrical stimulation of sacral nerve roots S3 or S4 with low electrical current via an electrode placed percutaneously through the sacral foramen. Patients usually undergo a temporary evaluation period, and if successful, an implantable pulse generator (IPG) is inserted. Although the mechanism of action of sacral neuromodulation (SNM) is still not fully elucidated, it seems to involve modulation of spinal cord reflexes and brain networks by peripheral afferents. Nevertheless, motor effects mediated via efferents on direct stimulation cannot be fully excluded (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eWe have already indicated that SNM may be effective in the treatment of endometriosis patients with CPP (\u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). This is the first study reporting long-term results of SNM in patients with CPP related to endometriosis.\u003c/p\u003e"},{"header":"Materials and methods","content":"\u003cp\u003eAll the endometriosis patients treated with SNM for CPP in Finland between 2004 and 2017 were included. There were four centers in which SNM was performed: Oulu and Turku University Hospitals, as well as Jyv\u0026auml;skyl\u0026auml; and Sein\u0026auml;joki Central Hospitals. SNM was performed in two stages. In the evaluation stage I, a tined lead was placed in the S3 or S4 foramina with the patient in prone Jack knife position under local or general anesthesia. After a trial period of 14 days, stage II was performed. The internal pulse generator (IPG) was implanted after a successful test period, meaning at least a 50% clinical improvement of symptoms.\u003c/p\u003e \u003cp\u003eSNM related data was collected from patient records in 2017 and was later completed with endometriosis related data in autumn 2023. Long-term results were assessed by phone questionnaire during spring 2021. Patients were asked if the SNM device was still functioning, what was the NRS pain evaluation and, alternatively, what was the cause of removal.\u003c/p\u003e \u003cp\u003eThe primary outcome was successfully sustained SNM therapy and the decrease of NRS pain score. Success was defined as having a permanent stimulator (IPG) implanted and as having a working SNM by the end of the follow-up. Secondary outcomes were failure of the treatment and postoperative morbidity.\u003c/p\u003e \u003cp\u003eStatistical analyses were performed using SPSS Statistics version 22 for Windows (IBM Corp, Armonk, NY, USA). Summary measurements were expressed as means with standard deviations or as medians with minimum and maximum values unless otherwise stated. Continuous variables were analyzed using Student\u0026rsquo;s t-test or Mann\u0026ndash;Whitney U-test, the latter for non-normally distributed data. Chi-square or Fisher\u0026rsquo;s exact test was used for categorical variables. Two-tailed P values were reported and a P value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was deemed statistically significant.\u003c/p\u003e \u003cp\u003e This study was conducted in accordance with Finnish Medical Research Act 488/199, 295/2004 and approved by the Ethics Committee of the Hospital District of Southwest Finland (ETMK: 163/1801/2015, ETMK 7/2019).\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 16 women, with a median age of 39 (25\u0026ndash;50) years, underwent SNM treatment for CPP related to endometriosis, with a median follow-up time of 73 (48\u0026ndash;85) months. All the patients had previously undergone at least one surgery due to endometriosis, with a median of 3 (\u003cspan additionalcitationids=\"CR2 CR3 CR4 CR5\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e) operations. Deep endometriosis (88%) was more frequent than superficial endometriosis (38%) and endometrioma (44%). A significant number of patients have undergone extensive surgery including hysterectomy (44%), adnexectomy (56%) and sigmoid resection or anterior resection of the rectum (44%). Baseline characteristics are presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. The patient flow chart is presented in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003eThe Implantable Pulse Generator (IPG) was implanted to 14 patients (88%). The majority of the patients had the SNM electrode implanted in S3 right (38%) or S4 right (38%) foramens, S3 left (19%) and S4 left (6.3%) were less commonly used. Postoperative complications were registered in five patients (31%) after Stage 1 (pain in three patients, cable dislodgement in one patient and cable snapping in one patient) and in two patients (14%) after Stage 2 (one with pain and one with infection, where IPG and electrode were replanted). By the end of the follow-up period 10 patients (62,5% of all patients and 71% of those who received IPG) had a functional SNM. Pain NRS value dropped from median 7.4 (3.6\u0026ndash;10) before SNM to 2.25 (0-6.5) by the end of the follow-up (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Postoperative outcomes are illustrated in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003eAnalysis of the two groups of patients with working SNM vs. failed SNM therapy by the end of the follow up showed no statistically significant differences when the type of endometriosis, the type of surgery or the number of surgeries were taken into consideration (Table \u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). The number of functional electrodes did not influence the final outcome. Median number (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan additionalcitationids=\"CR3\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) of functional electrodes was the same in both groups (p\u0026thinsp;=\u0026thinsp;0.940).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eCPP is not currently an approved US Food and Drug Administration (FDA) indication for SNM. There is emerging data showing that SNM is effective in the treatment of CPP with multifactorial etiology (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). There are only a few studies showing good short-term results of SNM in the treatment of endometriosis related CPP (\u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e), but long-term data is lacking. This Finnish national study is the first to show promising long-term results in the difficult to treat group of endometriosis patients with CPP after surgery.\u003c/p\u003e \u003cp\u003eThe long-term efficacy of SNM in our study is reflected by the fact that 71% of the patients that received the IPG had a functioning device by the end of the follow-up and this is better than the reported SNM long-term outcomes with different etiologies (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). It is also illustrated by the decrease of the pain related NRS value from a median of 7.4 (3.6\u0026ndash;10) before SNM to 2.25 (0-6.5) by the time of follow-up.\u003c/p\u003e \u003cp\u003eThe complication rates are comparable with those reported in earlier studies (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). The overall implantation rate of 88% in our study is better than the implantation rate of 64.3% reported by a recent meta-analysis and systematic review of SNM in CPP, with a quite diverse etiology of pain (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). The implantation rate is also better than the one of 54,8% reported by another meta-analysis and systematic review of SNM in CPP (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eCPP affects women\u0026rsquo;s quality of life deeply. CPP is often associated with migraine and headache, regardless if CPP is related or not to endometriosis (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Endometriosis and CPP was reported to negatively impact all domains of life including physical, psychological, social, sexual, education and employment (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). A large multi-center study across Europe, UK and the USA found that the total cost per woman with endometriosis per year was \u0026euro;9579 with the bulk of costs (\u0026euro;6298) being due to absence from work (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). It has been shown that as little as a 10% reduction on a pain scale is needed to improve productivity (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAll the patients in our study underwent standard medical therapy and at least one surgery for endometriosis before SNM. According to literature, surgery does not reduce pain in 20\u0026ndash;28% of patients (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Post-surgical hormonal therapy has been advocated to improve the effectiveness of surgery and prevent recurrences, but it has been proven to be of limited or no benefit for endometriosis in general and for deep peritoneal endometriosis in particular (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). Given the amount of non-responders to surgery and the recurrence of pain, even though there is no evident recurrence of endometriosis in 23%, there is a need for evidence-based approaches that do not require surgery or taking hormones (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Diet, exercise, physiotherapy, acupuncture, psychotherapy could be considered (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e) and this is the area where SNM might play a role. It was suggested that a major contributing factor for endometriosis-associated pain are not the ectopic growths themselves, but rather the activity from nerves that have emerged from nearby tissues to innervate the growths, which affects the activity of neurons in the spinal cord and brain (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). This could explain why SNM is effective. Our study encourages the use of SNM in endometriosis patients with CPP post-surgery, regardless of the type of endometriosis or the extent of surgery performed.\u003c/p\u003e \u003cp\u003eThis study has a few limitations. This is a retrospective study. The total number of the patients is relatively small, but on the other hand this is a comprehensive national study including all the patients that underwent SNM therapy for endometriosis-associated CPP between 2004 and 2017. More studies are definitely needed in order to standardize the role of SNM in the treatment of endometriosis patients with persisting CPP after surgery.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eEndometriosis patients with chronic pelvic pain may benefit from SNM therapy after failure of standard medical and surgical therapy, regardless of the type of endometriosis or the extent of surgery performed. More studies are needed to identify which endometriosis patients benefit the most.\u003c/p\u003e "},{"header":"Abbreviations ","content":"\u003cp\u003eSNM (sacral neuromodulation), CPP (chronic pelvic pain), IPG (implantable pulse generator), FDA (US Food and Drug Administration)\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthics approval and consent to participate:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis study was conducted in accordance with Finnish Medical Research Act 488/199, 295/2004 and approved by the Ethics Committee of the Hospital District of Southwest Finland (ETMK: 163/1801/2015, ETMK 7/2019).\u003c/p\u003e\n\u003cp\u003eInformed consent to participate was obtained from all of the participants in the study.\u003c/p\u003e\n\u003cp\u003eConsent for publication\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003eAvailability of data and materials\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003eCompeting interests\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003eFunding\u003c/p\u003e\n\u003cp\u003eThis study was conducted without external funding.\u003c/p\u003e\n\u003cp\u003eAuthors\u0026apos; contributions\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAZ\u003c/strong\u003e: Manuscript writing, Data analysis, Project development, \u003cstrong\u003eEO\u003c/strong\u003e: Data collection, \u003cstrong\u003eJK\u003c/strong\u003e: Data collection, Project development, \u003cstrong\u003ePS\u003c/strong\u003e: Data collection, \u003cstrong\u003ePV\u003c/strong\u003e: Project development, \u003cstrong\u003eJM\u003c/strong\u003e-\u003cstrong\u003eK\u003c/strong\u003e: Data collection, revision, \u003cstrong\u003eTR\u003c/strong\u003e: Project development, \u003cstrong\u003eJS\u003c/strong\u003e: Data collection, \u003cstrong\u003eMU\u003c/strong\u003e: Data analysis, revision \u003cstrong\u003eML\u003c/strong\u003e: Project development and supervision, \u003cstrong\u003eTP\u003c/strong\u003e: Project development and supervision.\u003c/p\u003e\n\u003cp\u003eAcknowledgements\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eStatPearls. 2021.\u003c/li\u003e\n\u003cli\u003eGreig J, Mak Q, Furrer MA, Sahai A, Raison N. Sacral neuromodulation in the management of chronic pelvic pain: A systematic review and meta-analysis. Neurourol Urodyn. 2023;42(4):822-36. Epub 20230306. doi: 10.1002/nau.25167. PubMed PMID: 36877182.\u003c/li\u003e\n\u003cli\u003eMahran A, Baaklini G, Hassani D, Abolella HA, Safwat AS, Neudecker M, et al. Sacral neuromodulation treating chronic pelvic pain: a meta-analysis and systematic review of the literature. Int Urogynecol J. 2019. Epub 2019/03/16. doi: 10.1007/s00192-019-03898-w. PubMed PMID: 30874835.\u003c/li\u003e\n\u003cli\u003eGrinberg K, Sela Y, Nissanholtz-Gannot R. New Insights about Chronic Pelvic Pain Syndrome (CPPS). Int J Environ Res Public Health. 2020;17(9). Epub 20200426. doi: 10.3390/ijerph17093005. PubMed PMID: 32357440; PubMed Central PMCID: PMC7246747.\u003c/li\u003e\n\u003cli\u003eTriolo O, Lagan\u0026agrave; AS, Sturlese E. Chronic pelvic pain in endometriosis: an overview. J Clin Med Res. 2013;5(3):153-63. Epub 20130423. doi: 10.4021/jocmr1288w. PubMed PMID: 23671540; PubMed Central PMCID: PMC3651065.\u003c/li\u003e\n\u003cli\u003eMathias 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. doi: 10.1016/0029-7844(95)00458-0. PubMed PMID: 8598948.\u003c/li\u003e\n\u003cli\u003eDe Wachter S, Vaganee D, Kessler TM. Sacral Neuromodulation: Mechanism of Action. Eur Urol Focus. 2020;6(5):823-5. Epub 20200201. doi: 10.1016/j.euf.2019.11.018. PubMed PMID: 32019718.\u003c/li\u003e\n\u003cli\u003eLavonius 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. Epub 2017/04/04. doi: 10.1155/2017/2197831. PubMed PMID: 28367344; PubMed Central PMCID: PMC5358435.\u003c/li\u003e\n\u003cli\u003eZegrea A, Kirss J, Pinta T, Rautio T, Varpe P, Kairaluoma M, et al. Outcomes of sacral neuromodulation for chronic pelvic pain: a Finnish national multicenter study. Tech Coloproctol. 2020;24(3):215-20. Epub 20200121. doi: 10.1007/s10151-020-02148-2. PubMed PMID: 31965400.\u003c/li\u003e\n\u003cli\u003eZegrea A, Ojala E, Suvitie P, Varpe P, Huhtinen H, M\u0026auml;kel\u0026auml;-Kaikkonen J, et al. Sacral neuromodulation in endometriosis - A promising treatment option for chronic pelvic pain. Acta Obstet Gynecol Scand. 2023. Epub 20231009. doi: 10.1111/aogs.14690. PubMed PMID: 37814355.\u003c/li\u003e\n\u003cli\u003eBieze M, van Haaps AP, Kapural L, Li S, Ferguson K, de Vries R, et al. Spinal Cord Stimulation for Intractable Visceral Pain Originating from the Pelvic and Abdominal Region: A Narrative Review on a Possible New Indication for Patients with Therapy-Resistant Pain. J Pain Res. 2024;17:691-736. Epub 20240219. doi: 10.2147/JPR.S445616. PubMed PMID: 38405684; PubMed Central PMCID: PMC10887953.\u003c/li\u003e\n\u003cli\u003eIsmail S, Chartier-Kastler E, Perrouin-Verbe MA, Rose-Dite-Modestine J, Denys P, Ph\u0026eacute; V. Long-Term Functional Outcomes of S3 Sacral Neuromodulation for the Treatment of Idiopathic Overactive Bladder. Neuromodulation. 2017;20(8):825-9. Epub 20171002. doi: 10.1111/ner.12696. PubMed PMID: 28967986.\u003c/li\u003e\n\u003cli\u003eSiegel S, Noblett K, Mangel J, Bennett J, Griebling TL, Sutherland SE, et al. Five-Year Followup Results of a Prospective, Multicenter Study of Patients with Overactive Bladder Treated with Sacral Neuromodulation. J Urol. 2018;199(1):229-36. Epub 20170711. doi: 10.1016/j.juro.2017.07.010. PubMed PMID: 28709886.\u003c/li\u003e\n\u003cli\u003eKarp BI, Sinaii N, Nieman LK, Silberstein SD, Stratton P. Migraine in women with chronic pelvic pain with and without endometriosis. Fertil Steril. 2011;95(3):895-9. Epub 20101210. doi: 10.1016/j.fertnstert.2010.11.037. PubMed PMID: 21145540; PubMed Central PMCID: PMC3415219.\u003c/li\u003e\n\u003cli\u003eBall E, Khan KS. Recent advances in understanding and managing chronic pelvic pain in women with special consideration to endometriosis. F1000Res. 2020;9. Epub 20200204. doi: 10.12688/f1000research.20750.1. PubMed PMID: 32089831; PubMed Central PMCID: PMC7001750.\u003c/li\u003e\n\u003cli\u003eSimoens S, Dunselman G, Dirksen C, Hummelshoj L, Bokor A, Brandes I, et al. The burden of endometriosis: costs and quality of life of women with endometriosis and treated in referral centres. Hum Reprod. 2012;27(5):1292-9. Epub 20120314. doi: 10.1093/humrep/des073. PubMed PMID: 22422778.\u003c/li\u003e\n\u003cli\u003eGerlinger C, Schumacher U, Faustmann T, Colligs A, Schmitz H, Seitz C. Defining a minimal clinically important difference for endometriosis-associated pelvic pain measured on a visual analog scale: analyses of two placebo-controlled, randomized trials. Health Qual Life Outcomes. 2010;8:138. Epub 2010/11/24. doi: 10.1186/1477-7525-8-138. PubMed PMID: 21106059; PubMed Central PMCID: PMC3002916.\u003c/li\u003e\n\u003cli\u003eAbbott J, Hawe J, Hunter D, Holmes M, Finn P, Garry R. Laparoscopic excision of endometriosis: a randomized, placebo-controlled trial. Fertil Steril. 2004;82(4):878-84. doi: 10.1016/j.fertnstert.2004.03.046. PubMed PMID: 15482763.\u003c/li\u003e\n\u003cli\u003eSomigliana E, Busnelli A, Benaglia L, Vigan\u0026ograve; P, Leonardi M, Paffoni A, et al. Postoperative hormonal therapy after surgical excision of deep endometriosis. Eur J Obstet Gynecol Reprod Biol. 2017;209:77-80. Epub 20160401. doi: 10.1016/j.ejogrb.2016.03.030. PubMed PMID: 27067871.\u003c/li\u003e\n\u003cli\u003eStratton P, Berkley KJ. Chronic pelvic pain and endometriosis: translational evidence of the relationship and implications. Hum Reprod Update. 2011;17(3):327-46. Epub 2010/11/23. doi: 10.1093/humupd/dmq050. PubMed PMID: 21106492; PubMed Central PMCID: PMC3072022.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBaseline characteristics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge, median (min-max)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e39 (25\u0026ndash;50)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFollow-up time, median (min-max)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e73 months (48\u0026ndash;85)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eG, median (min-max)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (0\u0026ndash;3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP, median (min-max)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0\u0026ndash;2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSuperficial endometriosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (38)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDeep endometriosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14 (88)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEndometrioma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (44)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEndometrioma enucleation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (44)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHysterectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (44)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSalpingectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (56)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOvariectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (56)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSuperficial peritoneal endometriosis resection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (38)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnterior resection of rectum or sigmoid resection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (44)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of endometriosis surgeries, median (min-max)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (\u003cspan additionalcitationids=\"CR2 CR3 CR4 CR5\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLight opioides\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (63)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStrong opioides\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (38)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePostoperative SNM outcomes\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eStage 1 test\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16 (100)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStage 1 complications\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (31)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eStage 2 implantation rate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14 (88)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStage 2 complications\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWorking SNM at the end of follow-up\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (71)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNRS at the end of the follow-up, median (min-max)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.25 (0-6.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparative analysis of patients with working SNM vs. failed SNM therapy\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWorking SNM\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFailed therapy\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e33 (29\u0026ndash;40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26 (25\u0026ndash;27)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.562\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperative pain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (3.6\u0026ndash;8.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9.5 (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.095\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSuperficial endometriosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.118\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDeep endometriosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (57)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (43)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.500\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEndometrioma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (86)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.145\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEndometrioma enucleation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (86)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.145\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHysterectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (71)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (29)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.633\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSalpingectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (78)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (22)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.302\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOvariectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (78)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (22)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.302\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSuperficial peritoneal endometriosis resection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.118\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnterior resection of rectum or sigmoid resection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (57)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (43)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.999\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of endometriosis surgeries, median (min-max)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (\u003cspan additionalcitationids=\"CR2 CR3 CR4 CR5\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (\u003cspan additionalcitationids=\"CR2 CR3 CR4 CR5\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.635\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLight opioides\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (70)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.726\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStrong opioides\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.915\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of electrodes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (\u003cspan additionalcitationids=\"CR3\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (\u003cspan additionalcitationids=\"CR3\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.940\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-womens-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmwh","sideBox":"Learn more about [BMC Women's Health](http://bmcwomenshealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bmwh/default.aspx","title":"BMC Women's Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"endometriosis, chronic pelvic pain, sacral neuromodulation","lastPublishedDoi":"10.21203/rs.3.rs-4088264/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4088264/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eSacral neuromodulation (SNM) is an established therapy in urology and gastroenterological surgery for treatment of overactive bladder symptoms, urge urinary incontinence or fecal incontinence. SNM has also been used with good results in patients with chronic pelvic pain (CPP). Our aim was to analyze long-term results of SNM in Finnish patients with endometriosis related CPP.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis is a register-based retrospective study including all the endometriosis patients treated with SNM for CPP in Finland between 2004 and 2017. There were four centers where these procedures were performed, two University Hospitals and two Central Hospitals. Long-term results were assessed by phone interview in spring 2021.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eA total of 16 women with endometriosis, with a median age of 39 (25\u0026ndash;50) years, underwent SNM treatment for chronic pelvic pain (CPP), with the median follow-up time of 73 (48\u0026ndash;85) months. The Implantable Pulse Generator (IPG) was implanted to 14 patients (88%). By the end of the follow-up period, 10 patients (62,5% of all patients and 71% of those who received IPG) had a functional SNM. Pain was assessed by numeral rating scale (NRS) and decreased from a median of 7.4 (3.6\u0026ndash;10) to 2.25 (0-6.5).\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eSNM could be a good option in the treatment of endometriosis related chronic pelvic pain when standard therapy is not enough.\u003c/p\u003e","manuscriptTitle":"Good long-term results of sacral neuromodulation for endometriosis related chronic pelvic pain","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-03-18 14:15:06","doi":"10.21203/rs.3.rs-4088264/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-04-03T13:10:22+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-04-03T12:45:55+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-03-14T17:59:06+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Women's Health","date":"2024-03-13T01:01:47+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-womens-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmwh","sideBox":"Learn more about [BMC Women's Health](http://bmcwomenshealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bmwh/default.aspx","title":"BMC Women's Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"82f64040-7bec-4360-9a4d-cc809ef3c752","owner":[],"postedDate":"March 18th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-04-14T16:12:51+00:00","versionOfRecord":{"articleIdentity":"rs-4088264","link":"https://doi.org/10.1186/s12905-025-03699-y","journal":{"identity":"bmc-womens-health","isVorOnly":false,"title":"BMC Women's Health"},"publishedOn":"2025-04-07 16:04:58","publishedOnDateReadable":"April 7th, 2025"},"versionCreatedAt":"2024-03-18 14:15:06","video":"","vorDoi":"10.1186/s12905-025-03699-y","vorDoiUrl":"https://doi.org/10.1186/s12905-025-03699-y","workflowStages":[]},"version":"v1","identity":"rs-4088264","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4088264","identity":"rs-4088264","version":["v1"]},"buildId":"WvIrzKhiLBfengagbw6Ux","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}