Neuromodulation of Pelvic Visceral Pain: Review of the Literature and Case Series of Potential Novel Targets for Treatment

Abstract

Chronic pelvic pain (CPP) is complex and often resistant to treatment. While the exact pathophysiology is unknown, the pain states resultant from conditions such as interstitial cystitis and the like yield patients with a presentation that bears a striking similarity to neuropathic syndromes that are known to respond to neuromodulation. While there has been past success using the sacral region as a target for spinal cord stimulation (SCS) to treat these patients, there remains to be a consensus on the optimal location for lead placement. In this article, the authors discuss the potential etiology of CPP, examine the current literature on lead placement for SCS as a method of treatment, as well as present several cases where novel lead placement was successfully employed. n

Dorsal Root Ganglion Stimulation for Chronic Pelvic Pain: A Case Series and Technical Report on a Novel Lead Configuration

“…In the United States, the annual healthcare costs related to diagnostic workup and treatment of CPP, in women alone, approaches nearly three billion dollars per year . Despite the fact that several, well‐known conditions are recognized to predispose one to develop CPP, the exact cause is largely unknown . The term “CPP” encompasses a variety of chronic pain conditions, including coccydynia, proctalgia, pudendal neuralgia, and vulvodynia to name a few.…”

New Directions in the Treatment of Pelvic Pain

“…There is new evidence that altering lead location can increase success rates in complex patients. Hunter et al have described lead placement as high as T6/7 and as low as the conus with positive results [28]. The success of high lead placement is attributed to the non dermatomal distribution of visceral pain fibers and the assumption that at higher levels, a greater percentage of visceral fiber coverage is achieved [28].…”

“…Hunter et al have described lead placement as high as T6/7 and as low as the conus with positive results [28]. The success of high lead placement is attributed to the non dermatomal distribution of visceral pain fibers and the assumption that at higher levels, a greater percentage of visceral fiber coverage is achieved [28]. Placement of leads in the sub-cutaneous tissue of the lower abdomen, as well as pudendal nerve neuromodulation, has also been described in difficult to treat patients with encouraging results [29,30].…”

Neuromodulation in male chronic pelvic pain syndrome: rationale and practice

“…18,19 With that in mind, most patients treated with neuromodulation for pelvic pain have electrodes placed at spinal levels that do not include these fibers. Hunter and colleagues have described placing epidural electrodes at novel targets in the thoracic spine region that achieved good pelvic and genital pain relief 20 . While neuromodulation at these spinal levels seems beyond the reach of the sacral fibers complicit in the transmission of pain from the pelvis, the organization of the spinal cord and sympathetic fibers seems to allow for sustained pain relief.…”

“…While neuromodulation at these spinal levels seems beyond the reach of the sacral fibers complicit in the transmission of pain from the pelvis, the organization of the spinal cord and sympathetic fibers seems to allow for sustained pain relief. 20 …”