Sacral neuromodulation in the management of chronic pelvic pain: A systematic review and meta‐analysis

Abstract

Introduction Sacral neuromodulation (SNM) is a treatment approved for use in several conditions including refractory overactive bladder (OAB) and voiding dysfunction. Chronic pelvic pain (CPP) is a debilitating condition for which treatment is often challenging. SNM shows promising effect in patients with refractory CPP. However, there is a lack of clear evidence, especially in long‐term outcomes. This systematic review will assess outcomes of SNM for treating CPP. Methods A systematic search of MEDLINE, Embase, Cochrane Central and clinical trial databases was completed from database inception until January 14, 2022. Studies using original data investigating SNM in an adult population with CPP which recorded pre and posttreatment pain scores were selected. Primary outcome was numerical change in pain score. Secondary outcomes were quality of life assessment and change in medication use and all‐time complications of SNM. Risk of bias was assessed using the Newcastle Ottawa Tool for cohort studies. Results Twenty‐six of 1026 identified articles were selected evaluating 853 patients with CPP. The implantation rate after test‐phase success was 64.3%. Significant improvement of pain scores was reported in 13 studies; three studies reported no significant change. WMD in pain scores on a 10‐point scale was −4.64 (95% confidence interval [CI] = −5.32 to −3.95, p < 0.00001) across 20 studies which were quantitatively synthesized: effects were maintained at long‐term follow‐up. Mean follow‐up was 42.5 months (0–59). Quality of life was measured by RAND SF‐36 and EQ‐5D questionnaires and all studies reported improvement in quality of life. One hundred and eighty‐nine complications were reported in 1555 patients (Clavien‐Dindo Grade I‐IIIb). Risk of bias ranged from low to high risk. Studies were case series and bias stemmed from selection bias and loss to follow‐up. Conclusion Sacral Neuromodulation is a reasonably effective treatment of Chronic Pelvic Pain and significantly reduces pain and increases patients’ quality of life with immediate to long‐term effects.

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

“…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).…”

“…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), signi cantly reducing pain and increasing patients' quality of life with immediate to long-term effects (2,3).…”

Current position of neuromodulation for bladder pain syndrome/interstitial cystitis

“…This success rate has also recently been highlighted in a meta-analysis by Greig et al [15 ▪▪ ]. They evaluated a total of 853 patients with CPPS; however, a large number of studies report on IC or BPS.…”

“…Similar to the previous mentioned studies, the success rate after test phase was 64.3%. An overall meta-analysis of reported pain scores using a visual analogue scale (VAS) showed a mean reduction of -4.64 points and a mean reduction of -4.55 points for IC/BPS patients specifically [ 15 ▪▪ ]. SNM is a promising treatment modality for IC/BPS; however, evidence is restricted to small numbers or retrospective analysis.…”

Surgical cure of chronic pelvic pain in the female by uterosacral ligament repair

“…I have no criticisms for the paper by Greig et al 1 It is an excellent meta-analysis of sacral nerve stimulation for chronic pelvic pain (CPP). 1 The purpose of this letter is to comment on the commonly held view expressed in the introduction, that CPP was "poorly understood," and without cure.…”