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

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

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

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

SNM is an effective therapy for CPP in both IC/BSP and non-IC/BSP patients, with better results in non-IC/BSP patients. Outcomes of the antegrade caudal approach were comparable with the standard retrograde approach. Similar content being viewed by others Abbreviations - SNM: - Sacral neuromodulation - CPP: - Chronic pelvic pain - VAS: - Visual analog scale - IC: - Interstitial cystitis - BPS: - Bladder pain syndrome - WMD: - Weighted mean difference - PNE: - Percutaneous nerve evaluation

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Electronic supplementary material ESM 1 (download DOCX ) (DOCX 21.5 kb) ESM 2 (download DOCX ) (DOCX 15.8 kb) Appendix Appendix Database(s): Ovid MEDLINE(R) and Epub Ahead of Print, In-Process & Other Non-Indexed Citations and Daily 1946 to 14 September 2018. Search Strategy: No. | Searches | Results | 1 | exp Electric Stimulation Therapy/ | 72,449 | 2 | (electric adj2 stimulation*).ti,ab. | 5183 | 3 | (nerve adj2 stimulation*).ti,ab. | 21,658 | 4 | Neuromodulation*.mp. | 6090 | 5 | neurostimulat*.mp. | 2998 | 6 | or/1–5 | 98,181 | 7 | URINARY INCONTINENCE/or FECAL INCONTINENCE/or URINARY INCONTINENCE, URGE/or URINARY INCONTINENCE, STRESS/ | 37,753 | 8 | incontinence.ti,ab. | 42,912 | 9 | incontinent.ti,ab. | 3853 | 10 | exp Urinary Bladder Diseases/ | 95,824 | 11 | bladder.ti,ab. | 142,717 | 12 | cystitis.ti,ab. | 10,417 | 13 | Urination Disorders/ | 10,985 | 14 | (urin* adj2 disorder*).ti,ab. | 1609 | 15 | Pelvic Pain/ | 4796 | 16 | “pelvic pain”.ti,ab. | 8048 | 17 | or/7–16 | 230,545 | 18 | exp SACRUM/ | 8306 | 19 | sacrum.ti,ab. | 4813 | 20 | sacral.ti,ab. | 15,321 | 21 | or/18–20 | 22,162 | 22 | 6 and 17 and 21 | 1512 | 23 | limit 22 to animals | 150 | 24 | 22 not 23 | 1362 | 25 | limit 24 to (case reports or comment or editorial or letter) | 148 | 26 | 24 not 25 | 1214 | 27 | limit 26 to (english language and last 30 years) | 1061 | 28 | from 27 keep 1–1061 | 1061 | PubMed Medline (((((((((((Electric Stimulation Therapy[MeSH Terms]) OR electric stimulation*[Title/Abstract]) OR nerve stimulation*[Title/Abstract]) OR Neuromodulation*) OR neurostimulat*[Title/Abstract])) AND ((((((((((((((URINARY INCONTINENCE[MeSH Terms]) OR FECAL INCONTINENCE[MeSH Terms]) OR urinary incontinence, urge[MeSH Terms]) OR urinary incontinence, stress[MeSH Terms])) OR incontinence[Title/Abstract]) OR incontinent[Title/Abstract]) OR Urinary Bladder Diseases[MeSH Terms]) OR bladder[Title/Abstract]) OR cystitis[Title/Abstract]) OR Urination Disorders[MeSH Terms]) OR Urination Disorder*[Title/Abstract]) OR “Pelvic Pain”[Mesh:noexp]) OR pelvic pain[Title/Abstract])) AND (((SACRUM[MeSH Terms]) OR sacrum[Title/Abstract]) OR sacral[Title/Abstract]))) NOT (((((((((Electric Stimulation Therapy[MeSH Terms]) OR electric stimulation*[Title/Abstract]) OR nerve stimulation*[Title/Abstract]) OR Neuromodulation*) OR neurostimulat*[Title/Abstract])) AND ((((((((((((((URINARY INCONTINENCE[MeSH Terms]) OR FECAL INCONTINENCE[MeSH Terms]) OR urinary incontinence, urge[MeSH Terms]) OR urinary incontinence, stress[MeSH Terms])) OR incontinence[Title/Abstract]) OR incontinent[Title/Abstract]) OR Urinary Bladder Diseases[MeSH Terms]) OR bladder[Title/Abstract]) OR cystitis[Title/Abstract]) OR Urination Disorders[MeSH Terms]) OR Urination Disorder*[Title/Abstract]) OR “Pelvic Pain”[Mesh:noexp]) OR pelvic pain[Title/Abstract])) AND (((SACRUM[MeSH Terms]) OR sacrum[Title/Abstract]) OR sacral[Title/Abstract])) AND ((Case Reports[ptyp] OR Comment[sb] OR Editorial[ptyp] OR Letter[ptyp]))))) NOT (((((((((((Electric Stimulation Therapy[MeSH Terms]) OR electric stimulation*[Title/Abstract]) OR nerve stimulation*[Title/Abstract]) OR Neuromodulation*) OR neurostimulat*[Title/Abstract])) AND ((((((((((((((URINARY INCONTINENCE[MeSH Terms]) OR FECAL INCONTINENCE[MeSH Terms]) OR urinary incontinence, urge[MeSH Terms]) OR urinary incontinence, stress[MeSH Terms])) OR incontinence[Title/Abstract]) OR incontinent[Title/Abstract]) OR Urinary Bladder Diseases[MeSH Terms]) OR bladder[Title/Abstract]) OR cystitis[Title/Abstract]) OR Urination Disorders[MeSH Terms]) OR Urination Disorder*[Title/Abstract]) OR “Pelvic Pain”[Mesh:noexp]) OR pelvic pain[Title/Abstract])) AND (((SACRUM[MeSH Terms]) OR sacrum[Title/Abstract]) OR sacral[Title/Abstract]))) NOT (((((((((Electric Stimulation Therapy[MeSH Terms]) OR electric stimulation*[Title/Abstract]) OR nerve stimulation*[Title/Abstract]) OR Neuromodulation*) OR neurostimulat*[Title/Abstract])) AND ((((((((((((((URINARY INCONTINENCE[MeSH Terms]) OR FECAL INCONTINENCE[MeSH Terms]) OR urinary incontinence, urge[MeSH Terms]) OR urinary incontinence, stress[MeSH Terms])) OR incontinence[Title/Abstract]) OR incontinent[Title/Abstract]) OR Urinary Bladder Diseases[MeSH Terms]) OR bladder[Title/Abstract]) OR cystitis[Title/Abstract]) OR Urination Disorders[MeSH Terms]) OR Urination Disorder*[Title/Abstract]) OR “Pelvic Pain”[Mesh:noexp]) OR pelvic pain[Title/Abstract])) AND (((SACRUM[MeSH Terms]) OR sacrum[Title/Abstract]) OR sacral[Title/Abstract])) AND ((Case Reports[ptyp] OR Comment[sb] OR Editorial[ptyp] OR Letter[ptyp])))) AND Animals[Mesh:noexp]) English language- 1988-2018. Embase Session Results (18 Sep 2018) No. | Query | Results | 30 | 27 NOT 28 AND [english]/lim AND [1988–2018]/py | 1212 | 29 | 27 NOT 28 | 1413 | 28 | 25 NOT 26 AND [animals]/lim | 177 | 27 | 25 NOT 26 | 1590 | 26 | 25 AND ‘case report’/de | 123 | 25 | 23 NOT 24 | 1713 | 24 | 23 AND (‘conference abstract’/it OR ‘conference paper’/it OR ‘conference review’/it OR ‘editorial’/it OR ‘letter’/it) | 1261 | 23 | 7 AND 11 AND 22 | 2974 | 22 | 12 OR 13 OR 14 OR 15 OR 16 OR 17 OR 18 OR 19 OR 20 OR 21 | 411,367 | 21 | pelvis NEAR/2 pain | 13,619 | 20 | pelvic NEAR/2 pain | 17,397 | 19 | ‘pelvic pain’/exp. OR ‘pelvic pain’ | 20,112 | 18 | ‘urination disorder’:ti,ab | 46 | 17 | ‘micturition disorder’/exp. OR ‘micturition disorder’ | 143,105 | 16 | cystitis:ti,ab | 15,122 | 15 | bladder:ti,ab | 200,602 | 14 | ‘bladder disease’/exp. OR ‘bladder disease’ | 168,493 | 13 | incontinence:ti,ab | 67,242 | 12 | ‘incontinence’/exp. OR ‘incontinence’ | 107,391 | 11 | 8 OR 9 OR 10 | 29,033 | 10 | sacral:ti,ab | 21,699 | 9 | sacrum:ti,ab | 6670 | 8 | ‘sacrum’/exp. OR ‘sacrum’ | 12,712 | 7 | 1 OR 2 OR 3 OR 4 OR 5 OR 6 | 280,338 | 6 | neurostimulat*:ti,ab | 4112 | 5 | neuromodulation | 44,386 | 4 | ‘neuromodulation’/exp. OR ‘neuromodulation’ | 44,386 | 3 | nerve NEAR/2 stimulation | 70,552 | 2 | electric NEAR/2 stimulation | 7840 | 1 | ‘electrotherapy’/exp. OR ‘electrotherapy’ | Web of Science TS = (“electric stimulation therapy” OR electric NEAR/2 stimulation OR nerve NEAR/2 stimulation OR neuromodulation* OR neurostimulat*) AND TS = (incontinence OR incontinent OR bladder or cystitis OR “urination disorder*” OR urin* NEAR/2 disorder* OR pelvic pain) AND TS = (sacrum OR sacral))ANDLANGUAGE: (English) AND DOCUMENT TYPES: (Article). Indexes = SCI-EXPANDED Timespan = 1988–2018. Rights and permissions About this article Cite this article Mahran, A., Baaklini, G., Hassani, D. et al. Sacral neuromodulation treating chronic pelvic pain: a meta-analysis and systematic review of the literature. Int Urogynecol J 30, 1023–1035 (2019). https://doi.org/10.1007/s00192-019-03898-w Received: Accepted: Published: Version of record: Issue date: DOI: https://doi.org/10.1007/s00192-019-03898-w