Neuromodulation in Intractable Interstitial Cystitis and Related Pelvic Pain Syndromes

Abstract

Many people suffering with interstitial cystitis (IC) and related pelvic pain syndromes do not benefit from the standard medical or surgical treatments. The pathophysiology of IC bears striking similarities to a wide variety of disorders driven by neurogenic inflammation, many of which may someday be controlled through neuromodulation. Because the bladder is accessible to repeated inspection, functional monitoring, biopsy, and collection of effluents, the study of neuromodulation in IC promises to yield important insights into the successful application of neuromodulatory approaches to diseases of the pelvis and other areas. Clinical experience suggests that neuromodulation in pelvic pain syndromes can successfully normalize the motor function of the bladder and pelvic muscles, as well as their sensoria. Useful neuromodulatory approaches that have potential for the treatment of intractable IC and related syndromes, such as certain cases of chronic prostatitis and pelvic floor dysfunction, include stimulation of afferent pathways using high-frequency stimulation of sacral roots and low-frequency stimulation of motor fibers innervating pelvic floor muscles via sacral roots or the posterior tibial nerve. While the lifetime incidence of chronic pelvic pain in American women is estimated to be as high as 33%, fewer than 1% of these patients are ever seen by pain specialists. Developing neuromodulatory strategies for IC and pelvic pain may also hold promise for the effective treatment of certain syndromes involving intractable urinary retention, lower bowel disorders, or sexual dysfunction.

Vulvodynia: A Psychophysiological Profile Based on Electromyographic Assessment

“…discomfort, burning and stinging sensation). Several studies of these co-morbidities have confirmed muscle over-activation, lack of voluntary control, inability to relax, shortening of muscles and trigger point referred pain, as well as hypersensitivity exacerbated by anxiety, sexual and physical activity (Bernstein et al 1992;Brookoff and Bennet 2006;Fitzgerald and Kotarinos 2003a, b;Oemler et al 2006;Weiss 2001). Ultimately, further research into these co-morbidities is required (Arnold et al 2006) but may show that vestibulodynia, clitorodynia, generalized vulvodynia, urethral syndrome and abacterial interstitial cystitis may share a common mediating mechanism and may be symptomatic of pelvic muscle dysfunction distinguished only by the locale of the pain.…”

Bladder hyperactivity and increased excitability of bladder afferent neurons associated with reduced expression of Kv1.4 α-subunit in rats with cystitis

“…While the etiology is unknown, theories explaining the pathophysiology of PBS/IC include an altered urothelial barrier, neurogenic inflammation including mast cell infiltration and afferent sensitization (6,7,36,61). A recent study using cats with naturally occurring feline-type IC has demonstrated that capsaicin-sensitive DRG neurons exhibited an increase in cell size and had increased firing rates to depolarizing current pulses due to a reduction in low-threshold K ϩ currents elicited by membrane depolarization between Ϫ50 to Ϫ30 mV (46), as similarly found in our present and previous studies using cystitis rats.…”

Minimally Invasive Therapies for Chronic Pelvic Pain Syndrome

“…SNM lessened intractable pelvic pain in these patients [64,65]. It is thought that by reestablishing pelvic floor muscle awareness, pelvic floor hypertonus can be decreased, which not only reduces symptoms of pelvic pain but also helps relieve symptoms such as daytime frequency and nocturia [63]. SNM is a promising new avenue for the treatment of refractory UCPPS [66].…”

“…SNM is a potential therapy for UCPPS associated with pelvic floor dysfunction. Small studies have demonstrated this fact through the stimulation of afferent pathways of sacral roots and of motor fibers innervating pelvic floor muscles [63]. SNM lessened intractable pelvic pain in these patients [64,65].…”