Bladder pain syndrome/interstitial cystitis (BPS/IC) is a common debilitating disease and there has not been consistently effective treatment. We aimed to evaluate all available literature regarding the efficacy and safety of sacral neuromodulation (SNM) for refractory BPS/IC. A comprehensive search of Pubmed, Web of Science and Cochrane Library through May 2016 was conducted. A total of 17 studies enrolling 583 patients were identified. Pooled analyses demonstrated that SNM was associated with great reduction in pelvic pain (weighted mean difference [WMD] −3.99; 95% confidence interval [CI] −5.22 to −2.76; p < 0.00001), Interstitial Cystitis Problem and Symptom Index scores (WMD −6.34; 95% CI −9.57 to −3.10; p = 0.0001; and WMD −7.17; 95% CI −9.90 to −4.45; p < 0.00001, respectively), daytime frequency (WMD −7.45; 95% CI −9.68 to −5.22; p < 0.00001), nocturia (WMD −3.01; 95% CI −3.56 to −2.45; p < 0.00001), voids per 24 hours (WMD −9.32; 95% CI −10.90 to −7.74; p < 0.00001) and urgency (WMD −1.08; 95% CI −1.79 to −0.37; p = 0.003) as well as significant improvement in average voided volume (WMD 95.16 ml; 95% CI 63.64 to 126.69; p < 0.0001). The pooled treatment success rate was 84% (95% CI 76% to 91%). SNM-related adverse events were minimal. Current evidence indicates that SNM might be effective and safe for treating refractory BPS/IC.
Bladder pain syndrome/interstitial cystitis (BPS/IC) is a chronic distressing disease, characterized by persistent or recurrent pelvic pain perceived to be related to bladder filling, associated with at least one other lower urinary tract symptom, without the evidence of a distinctively identifiable cause1. A recent report demonstrates BPS/IC is more common than previously thought, with a prevalence of 6.5% in adult females in the United States2. BPS/IC has a dramatic impact on patients’ quality of life3, 4. It often results in behavioral, emotional, psychological and even social problems4.
It has been reported that there are more than 180 treatments available for BPS/IC, but the results are usually varied5. It is estimated that 10% of patients with BPS/IC would progress to severe stage, refractory to conservative therapies6. The options to manage refractory BPS/IC include cystectomy with urinary diversion and bladder augmentation. Unfortunately, these interventions are associated with significant complications and often fail to alleviate the severity of pain7.
Sacral neuromodulation (SNM), introduced as a minimally invasive procedure in the 1980s, has previously been approved by the Food and Drug Administration to manage intractable overactive bladder symptoms and non-obstructive urinary retention8, 9. The transforaminal sacral afferent roots are stimulated by an implantable lead and electrode.SNM might also be a valuable option for patients with refractory BPS/IC. Several studies examining the effect of SNM in patients with refractory BPS/IC have been reported, but most included very few subjects and the results were conflicting10,11,12,13,14,15. Therefore, we systematically searched and analyzed published literature on the efficacy and safety of SNM in the treatment of refractory BPS/IC.
After screening 472 articles, 17 studies including 583 subjects were included in the final analysis (Fig. 1), one RCT13, eight prospective cohort studies12, 14, 16,17,18,19,20,21 and eight retrospective case series10, 11, 15, 22,23,24,25,26.
Description of eligible studies
The main characteristics of the 17 studies are summarized in Table 1. BPS/IC was diagnosed using the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) criteria12, 14,15,16, 18, 24,25,26, or by clinical criteria and cystoscopic findings10, 11, 13, 17, 19, 21, 27. Two studies did not state their diagnostic criteria20, 23. All patients included in the study had failed conservative management, with a BPS/IC duration ranging from 3 to 9.1 years. All studies aimed to assess the efficacy and safety of SNM in the treatment of refractory BPS/IC. The participants were predominantly female (89%, 519 of 583) and the follow-up time ranged from test stimulation to 86 months.
Twelve trials assessed pelvic pain using the VAS in 178 patients10, 12, 14,15,16,17,18,19, 21,22,23, 26. Pooled analysis showed that SNM significantly decreased VAS compared to baseline (WMD −3.99; 95% CI −5.22 to −2.76; p < 0.00001) (Fig. 2).
Interstitial cystitis problem index and interstitial cystitis symptom index
One RCT and two prospective studies reported ICPI and ICSI scores12,13,14. Pooling the data of these three studies showed significant reduction in ICPI scores (WMD −6.34; 95% CI −9.57 to −3.10; p = 0.0001; Fig. 3) and ICSI scores (WMD −7.17; 95% CI −9.90 to −4.45; p < 0.00001; Fig. 4) following SNM.
Ten studies assessed the success rate in 258 patients that ranged between 60% and 98%10,11,12, 14, 15, 18, 19, 21, 25, 26, and pooled analysis demonstrated that the success rate was 84% (95% CI 76% to 91%; Fig. 5).
Daytime frequency, nocturia and voids per 24 hours
Four studies12, 15, 18, 24 assessed daytime frequencies and two other studies assessed nocturia22, 26. Pooled analysis detected significant improvement in both daytime frequency (WMD −7.45; 95% CI −9.68 to −5.22; p < 0.00001; Fig. 6) and nocturia (WMD −3.01; 95% CI −3.56 to −2.45; p < 0.00001; Fig. 7). Pooling the data of six studies that reported voids per 24 hours demonstrated a significant difference favoring SNM (WMD −9.32; 95% CI −10.90 to −7.74; p < 0.00001; Table 2, Supplemental Fig. S1), consistent with the results of daytime frequency and nocturia12,13,14, 16, 22, 26.
Four studies assessing the efficacy of SNM, included analysis of urgency14,15,16, 18. Pooling the data from these four studies demonstrated a significant reduction in urgency (WMD −1.08; 95% CI −1.79 to −0.37; p = 0.003; Table 2, Supplemental Fig. S2) following SNM.
Average voided volume
Six studies reported baseline and post-treatment AVV10, 12,13,14, 22, 26. The pooled data showed a significant improvement in AVV (WMD 95.16 ml; 95% CI 63.64 to 126.69; p < 0.0001; Table 2, Supplemental Fig. S3), following SNM.
Complication rate and explantation rate
14 studies reported complication rates in 345 patients, ranging from 0% to 56%10,11,12,13,14,15,16,17,18, 20,21,22,23, 25. Pooling the data demonstrated an overall complication rate of 3% (95% CI 0 to 11%; Fig. 8). Pooling the data of 10 studies including 258 patients that reported explantation rate showed an overall explantation rate of 8% (95% CI 3% to 13%; Table 2, Supplemental Fig. S4)10,11,12,13, 15, 17, 19,20,21, 25.
Short-term and long-term subgroup analyses were consistent with the original analysis. Short-term subgroup had a slightly higher success rate, slightly lower complication rate and explantation rate compared to the long-term subgroup.
Sensitivity analysis and meta-regression
Ten or more studies assessing SNM included analysis of VAS, success rate, complication rate and explantation rate. Sensitivity analyses did not show significant change in these results. In addition, meta-regression analyses did not detect significant correlations between publication year or type of study design and the above four outcomes.
Risk of bias and publication bias
The risk of bias was satisfactory in the included studies (Supplemental Fig. S5 and S6). The funnel plot for VAS was largely symmetric, demonstrating no obvious publication bias in this present meta-analysis (p-values from the Begg test and Egger test were 0.451 and 0.567, respectively) (Supplemental Fig. S7).
This meta-analysis of 17 studies assessing the efficacy of SNM in the treatment of BPS/IC demonstrated that SNM was associated with significant improvement in pelvic pain, ICPI and ICSI scores, as well as neutralizing other symptoms including daytime frequency, nocturia, urgency and average voided volume.
During the last few decades, various modalities have been introduced for treating BPS/IC, such as oral drug therapy, intravesical instillations and surgery, but they have not provided consistent clinical improvement or relief 28, 29.
Since the pathogenesis of BPS/IC is still unclear, current treatment protocols are aimed at alleviating the symptoms. Our meta-analysis suggests that SNM effectively alleviates pelvic pain, with an average decrease of 3.99 in VAS score. This finding is encouraging for patients, as pelvic pain seriously affects their quality of life and could lead to other symptoms such as daytime frequency and nocturia1, 28.
The ICPI and ICSI scores have been widely accepted as reliable and validated measures of BPS/IC symptoms30. Significant improvements in ICSI and ICPI scores demonstrate that SNM has significant influence on the subjective symptoms.
The pooled data demonstrated that SNM was associated with a significant decrease in daytime frequency, nocturia and voids per 24h. This is very important, as increased voiding frequency can lower productivity, lead to considerable anxiety and prevent participation in social activities.
SNM technique was introduced in the 1980s and has recently become a widely used therapy for refractory urgency-incontinence, overactive bladder symptoms and non-obstructive urinary retention8, 9, 31. Following failed conservative treatment, SNM is considered to be the therapeutic option of choice for lower urinary tract dysfunction, before resorting to more invasive surgeries such as bladder augmentation and urinary diversion.
The exact etiology of BPS/IC remains to be clearly identified. There is emerging evidence of neural abnormalities both peripheral and central in BPS/IC, which plays an important role in pain sensitivity, urgency, and frequency symptoms27, 32. Dysregulated nervous system may not only maintain the perception of pain following acute injury, but also magnify pain perception in response to stimulus33. Specifically the precise mechanism of symptom relief caused by SNM is still not fully understood and it is believed that SNM may inhibit the transmission of abnormal sensory signals to the spinal cord and brain by acting on the afferent pathways34, 35. Spinal cord stimulation has been used to manage chronic pain conditions, including chronic back pain, idiopathic angina pectoris and migraine, with success34.
From this meta-analysis we cannot conclude whether bilateral or unilateral SNM should be the preferred therapeutic option. Considering that only a few studies assessed bilateral SNM and enrolled small number of patients, we did not perform formal subgroup comparison of bilateral versus unilateral stimulation. Further well-designed RCTs are warranted to determine this issue.
It is probable that the long-term efficacy of SNM in the treatment of BPS/IC decreases significantly. However, the subgroup analysis did not show significant differences between short-term and long-term improvement in symptoms. Clearly defined therapeutic success is very important in evaluating SNM efficacy. Most studies utilized more than 50% improvement in pelvic pain/ voiding symptoms as the therapeutic goal. It has been reported that SNM may lose efficacy overtime20. However, in this present meta-analysis, long-term success rate was found to be 76%, similar to short-term success rate at 88%, indicating SNM could provide good long-term efficacy.
The safety of any treatment is always of great importance and pooled analysis indicates that SNM is safe for BPS/IC. Complications were minimal, and most of them were pain at the site of the implantable pulse generator (IPG), infection and lead migration or dysfunction, which usually can be treated effectively. However, there was a slight increase in long-term complications and this could be attributed to IPG malfunction due to accidents (e.g., trauma to the pelvic region). The overall explantation rate was relatively low and the most common reasons for removal were loss of efficacy, painful stimulation, depleted batteries and technical malfunction. It seems reasonable to speculate that explantation rate will decrease continually as technology improves.
Although the findings of this first meta-analysis aiming to access SNM as a therapeutic option in refractory BPS/IC are promising, the following limitations must be taken into account. The main limitation is that the sample sizes of all included studies were small. Eight of the studies were retrospective case series. In general, case series studies are prone to increased risk of selection bias. However, outcomes reported by these case series were similar to the RCT13. Moreover, complication rate and explantation rate were 0 in several studies and had to be imputed. To calculate the overall complication rate and explantation rate, we assumed it to be 0.01. Therefore, one should be cautious when interpreting the summary rate reported. However, because sensitivity analyses did not show that these studies had significant influence on the results, we consider this approach to be acceptable. Finally, there was substantial heterogeneity between studies as well as scarcity of data that made subgroup analyses of bilateral versus unilateral stimulation and stimulation parameters impossible. To the best of our knowledge, the present study is the first meta-analysis to assess the efficacy and safety of SNM as a therapeutic option for BPS/IC. We applied multiple rigorous search strategies, strictly evaluating criteria and subgroup analysis, sensitivity and meta-regression analysis. Hence, this meta-analysis provides strong evidence in this area.
This meta-analysis indicates that SNM may be effective and safe for treating BPS/IC refractory to conventional therapies. This present study demonstrates marked improvements in not only pelvic pain, but also in voiding symptoms and improved symptom scores. Adverse events were minimal, transient and usually could be treated effectively and there were no irreversible or life threatening complications. In addition, the technique itself is completely reversible. However, considering the overall low quality of included studies, further well-designed, large-volume RCTs are required to reach definitive conclusions.
This systematic review and meta-analysis was performed following Preferred Reporting Items for Systematic reviews and Meta-Analysis guidelines36. A pre-specified protocol including objectives, literature-search strategies, eligibility criteria, outcome measurements, quality assessment and methods of statistical analyses was prepared.
A systematic literature search was performed in May 2016 without any restrictions for languages, regions, or publication types. We searched the electronic databases of Pubmed, Web of Science and Cochrane Library, using the search terms sacral neuromodulation, electric stimulation therapy, sacral nerve stimulation, neuromodulation, SNM and associated those with the search terms painful bladder syndrome, bladder painful syndrome, interstitial cystitis and chronic pelvic pain. The reference lists of all identified studies and reviews were screened to select relevant articles.
Inclusion and exclusion criteria
All available randomized controlled trials (RCTs), comparative studies and single-arm cohort studies that assessed effectiveness of SNM for treating BPS/IC, were considered to be eligible. Non-original articles, duplicate reports, case reports and studies using animal models were excluded.
Data extraction and outcomes of interest
Two authors (J. P. Wang and Y. Chen) independently extracted and summarized the data from the selected articles, including study characteristics (diagnostic criteria, study type, and follow-up), number of participants, SNM (percutaneous nerve evaluation or a two-staged procedure, unilateral or bilateral) and outcomes (primary and secondary outcomes). Any discrepancies in the extracted data were resolved by the senior author (P. Wu).
The primary outcomes evaluated were the 0–10 Visual Analog Scale (VAS), the Interstitial Cystitis Problem Index (ICPI), the Interstitial Cystitis Symptom Index (ICSI) and success rate. The secondary endpoints included daytime frequency, nocturia, voids per 24 hours, urgency, average voided volume, complication rate and explantation rate.
Assessment of risk of bias and statistical analysis
Risk of bias in RCTs was assessed using the Cochrane risk of bias assessment tool37. Methodological quality of comparative non-RCTs was assessed utilizing the described Cochrane tool and a predefined 8-point quality control measure38.
The meta-analyses were conducted using Review Manager 5.3 (Cochrane Collaboration, Oxford, UK) and the metan command of Stata v.12 (StataCorp, College Station, TX, USA). Weighted mean difference (WMD) was used for continuous outcomes and 95% confidence intervals (CIs) were applied for all outcomes. For studies that presented data as medians and range values, the means and standard deviations were calculated using the pragmatic approach described by Hozo et al.39.
Heterogeneity among studies was assessed by the chi-square test and I2 statistic. A p value < 0.10 or an I2 > 50% denoted the existence of significant heterogeneity. The fixed-effects model was used if no substantial heterogeneity was observed, otherwise, the random-effects model was used.
Subgroup analysis was performed to compare short-term and long-term effectiveness of SNM. Sensitivity analysis and meta-regression were performed to screen for potential sources of heterogeneity. Publication bias was assessed using funnel plots.
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van de Merwe, J. P. et al. Diagnostic Criteria, Classification, and Nomenclature for Painful Bladder Syndrome/Interstitial Cystitis: An ESSIC Proposal. Eur Urol 53, 60–67 (2008).
Berry, S. H. et al. Prevalence of Symptoms of Bladder Pain Syndrome/Interstitial Cystitis Among Adult Females in the United States. J Urol 186, 540–544 (2011).
Krieger, J. et al. Non-Urological Syndromes and Severity of Urological Pain Symptoms: Baseline Evaluation of the National Institutes of Health Multidisciplinary Approach to Pelvic Pain Study. J Urol 189S, E181 (2013).
Baranowski, A. P. Chronic Pelvic Pain. Best Pract Res Clin Gastroenterol 23, 593–610 (2009).
Rovner, E. et al. Treatments Used in Women with Interstitial Cystitis: The Interstitial Cystitis Data Base (ICDB) Study Experience. The Interstitial Cystitis Data Base Study Group. Urology 56, 940–945 (2000).
Webster, G. D. & Galloway, N. Surgical Treatment of Interstitial Cystitis. Indications, Techniques, and Results. Urology 29, 34–39 (1987).
Hohenfellner, M., Black, P., Linn, J. F., Dahms, S. E. & Thuroff, J. W. Surgical Treatment of Interstitial Cystitis in Women. Int Urogynecol J Pelvic Floor Dysfunct 11, 113–119 (2000).
Kohli, N. & Rosenblatt, P. L. Neuromodulation Techniques for the Treatment of the Overactive Bladder. Clin Obstet Gynecol 45, 218–232 (2002).
van Kerrebroeck, P. E. et al. Results of Sacral Neuromodulation Therapy for Urinary Voiding Dysfunction: Outcomes of a Prospective, Worldwide Clinical Study. J Urol 178, 2029–2034 (2007).
Gajewski, J. B. & Al-Zahrani, A. A. 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 107, 1258–1264 (2011).
Powell, C. R. & Kreder, K. J. Long-Term Outcomes of Urgency-Frequency Syndrome Due to Painful Bladder Syndrome Treated with Sacral Neuromodulation and Analysis of Failures. J Urol 183, 173–176 (2010).
Comiter, C. V. Sacral Neuromodulation for the Symptomatic Treatment of Refractory Interstitial Cystitis: A Prospective Study. J Urol 169, 1369–1373 (2003).
Peters, K. M., Feber, K. M. & Bennett, R. C. A Prospective, Single-Blind, Randomized Crossover Trial of Sacral Vs Pudendal Nerve Stimulation for Interstitial Cystitis. BJU Int 100, 835–839 (2007).
Whitmore, K. E., Payne, C. K., Diokno, A. C. & Lukban, J. C. Sacral Neuromodulation in Patients with Interstitial Cystitis: A Multicenter Clinical Trial. Int Urogynecol J Pelvic Floor Dysfunct 14, 305–309 (2003).
Ghazwani, Y. Q., Elkelini, M. S. & Hassouna, M. M. Efficacy of Sacral Neuromodulation in Treatment of Bladder Pain Syndrome: Long-Term Follow-Up. Neurourol Urodynam 30, 1271–1275 (2011).
Chai, T. C., Zhang, C., Warren, J. W. & Keay, S. Percutaneous Sacral Third Nerve Root Neurostimulation Improves Symptoms and Normalizes Urinary HB-EGF Levels and Antiproliferative Activity in Patients with Interstitial Cystitis. Urologyc 55, 643–646 (2000).
Kessler, T. M. et al. Sacral Neuromodulation for Refractory Lower Urinary Tract Dysfunction: Results of a Nationwide Registry in Switzerland. Eur Urol 51, 1357–1363 (2007).
Maher, C. F., Carey, M. P., Dwyer, P. L. & Schluter, P. L. Percutaneous Sacral Nerve Root Neuromodulation for Intractable Interstitial Cystitis. J Urol 165, 884–886 (2001).
Siegel, S., Paszkiewicz, E., Kirkpatrick, C., Hinkel, B. & Oleson, K. Sacral Nerve Stimulation in Patients with Chronic Intractable Pelvic Pain. J Urol 166, 1742–1745 (2001).
Zabihi, N., Mourtzinos, A., Maher, M. G., Raz, S. & Rodríguez, L. V. Short-Term Results of Bilateral S2–S4 Sacral Neuromodulation for the Treatment of Refractory Interstitial Cystitis, Painful Baldder Syndrome, and Chronic Pelvic Pain. Int Urogynecol J 19, 553–557 (2008).
Lavano, A. et al. Sacral Nerve Stimulation with Percutaneous Dorsal Transforamenal Approach in Treatment of Isolated Pelvic Pain Syndromes. Neuromodulation 9, 229–233 (2006).
Marinkovic, S. P., Gillen, L. M. & Marinkovic, C. M. Minimum 6-Year Outcomes for Interstitial Cystitis Treated with Sacral Neuromodulation. Int Urogynecol J 22, 407–412 (2011).
Sokal, P., Zieliński, P. & Harat, M. Sacral Roots Stimulation in Chronic Pelvic Pain. Neurol Neurochir Pol 49, 307–312 (2015).
Steinberg, A. C., Oyama, I. A. & Whitmore, K. E. Bilateral S3 Stimulator in Patients with Interstitial Cystitis. Urology 69, 441–443 (2007).
Peters, K. M., Carey, J. M. & Konstandt, D. B. Sacral Neuromodulation for the Treatment of Refractory Interstitial Cystitis: Outcomes Based On Technique. Int Urogynecol J Pelvic Floor Dysfunct 14, 223–228 (2003).
Yang, Y. et al. Sacral Neuromodulation for interstitial cystitis with pelvic floor pain (report of 4 cases). Chin J Urol 27, 765–767 (2006).
Kairys, A. E. et al. Increased Brain Gray Matter in the Primary Somatosensory Cortex is Associated with Increased Pain and Mood Disturbance in Patients with Interstitial Cystitis/Painful Bladder Syndrome. J Urol 193, 131–137 (2015).
Hanno, P. M., Erickson, D., Moldwin, R. & Faraday, M. M. Diagnosis and Treatment of Interstitial Cystitis/Bladder Pain Syndrome: AUA Guideline Amendment. J Urol 193, 1545–1553 (2015).
Hanno, P. & Dmochowski, R. Status of International Consensus On Interstitial Cystitis/Bladder Pain Syndrome/Painful Bladder Syndrome: 2008 Snapshot. Neurourol Urodynam 28, 274–286 (2009).
O’Leary, M. P., Sant, G. R., Fowler, F. J., Whitmore, K. E. & Spolarich-Kroll, J. The Interstitial Cystitis Symptom Index and Problem Index. Urology 49, 58–63 (1997).
Elkelini, M. & Hassouna, M. M. Canadian Experience in Sacral Neuromodulation. Urol Clin North Am 32, 41–49 (2005).
Nazif, O., Teichman, J. M. & Gebhart, G. F. Neural Upregulation in Interstitial Cystitis. Urology 69, 24–33 (2007).
Engeler, D. S. et al. The 2013 EAU Guidelines On Chronic Pelvic Pain: Is Management of Chronic Pelvic Pain a Habit, a Philosophy, Or a Science? 10 Years of Development. Eur Urol 64, 431–439 (2013).
Alo, K. M. & Holsheimer, J. New Trends in Neuromodulation for the Management of Neuropathic Pain. Neurosurgery 50, 690–704 (2002).
Wyndaele, J. J., Michielsen, D. & Van Dromme, S. Influence of Sacral Neuromodulation On Electrosensation of the Lower Urinary Tract. J Urol 163, 221–224 (2000).
Moher, D., Liberati, A., Tetzlaff, J. & Altman, D. G. Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. Plos Med 6, e1000097 (2009).
Higgins, J. P. et al. The Cochrane Collaboration’s Tool for Assessing Risk of Bias in Randomised Trials. BMJ 343, d5928 (2011).
Schneider, M. P. et al. Tibial Nerve Stimulation for Treating Neurogenic Lower Urinary Tract Dysfunction: A Systematic Review. Eur Urol 68, 859–867 (2015).
Hozo, S. P., Djulbegovic, B. & Hozo, I. Estimating the Mean and Variance From the Median, Range, and the Size of a Sample. Bmc Med Res Methodol 5, 13 (2005).
This work was supported by the Science and Technology Planning Project of Guangdong (grant no. 2014A020212195) and Natural Science Foundation of Guangdong (grant no. 2016A030313605).
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Sacral neuromodulation treating chronic pelvic pain: a meta-analysis and systematic review of the literature
International Urogynecology Journal (2019)