*3.4.1 CPPS and IC/BPS*

*Neurostimulation and Neuromodulation in Contemporary Therapeutic Practice*

infection and renal failure [9].

*3.3.1 Spinal cord injury*

*3.3.2 Multiple sclerosis*

outcomes [9, 105, 107].

*3.3.3 Diabetic cystopathy*

glycemic control [105].

upper tract deterioration from controlled voiding [4]. It is thus important to stress the need for proper assessment and continued evaluation of these patients as urinary retention, acute or chronic, could have consequences including urinary tract

SCI, especially complete transection, has long been accepted as a contraindication for sacral neuromodulation on the basis of a disturbed neural circuit. However, numerous reports have been reviewed that show promising results for SNM in the management of neurologically-stable SCI patients, even those with complete disruption [105]. In the acute phase of spinal shock where the bladder is atonic, SNM has been found to facilitate neurogenic remodeling as researchers theorize and

In a review of eight studies where SNM was employed in the management of lower urinary tract dysfunction in SCI patients, the success rate of the test phase was a shy 45%, but that later translated into a 75% success rate once the screened patients proceeded with IPG implantation. The treatment was well-tolerated and

MS is of special interest to neuro-urologists as the disease manifests with a spectrum of urinary symptoms and progresses with different patterns in this spectrum along the course of the disorder as well. Demyelination, the pathological hallmark of MS, eventually affects lower urinary tract nerves, resulting in dysfunction. Up to 80% of patients show neuro-urological symptoms within 10 years of diagnosis, most frequently bladder overactivity. As a matter of fact, voiding dysfunction is the

Though not FDA approved, neuromodulation has been applied in MS patients for years, and its efficacy has been repeatedly demonstrated. SNM and PTNS have been shown in a number of series to decrease urinary symptoms and improve the quality of life of MS patients who demonstrate bladder overactivity; however, although SNM is approved for NOUR, it has not shown any benefit for MS patients

What remains an important issue for MS patients being considered for SNM is appropriate patient counseling and communication with their treating physician or neurologist to assess the need for MRI examination in the future as well as stability of the disease, as disease progression and relapse would negatively affect the SNM

Diabetic cystopathy is a condition that describes the neuromuscular effect long-standing diabetes has on the urinary bladder. Part of the condition stems from diabetic neuropathy, while another part may stem from vasculopathy affecting the detrusor muscle itself. In the application of neuromodulation to the control of overactivity symptoms resulting from diabetic cystopathy, promising results from series were overshadowed by a substantially higher than average rate of infections (17%) compared to the accepted average, as would be expected from any foreign body implantation in diabetic patients especially those with poor

demonstrating "hypoactive" urinary bladders with retention [107, 108].

demonstrate sustained SNM effects and remodeling in the brain [9, 104].

safe without any unexpected adverse events [106].

first sign of the disease in up to 10% of patients [107].

**230**

Chronic pelvic pain syndrome in males and its predominantly female counterpart interstitial cystitis/bladder pain syndrome are chronic conditions of pelvic pain and voiding dysfunction with a poorly understood etiology [109]. Off-label use of SNM in the treatment of these disorders is established with significant results, and similar to its unknown etiology, the way SNM provides subjective and objective improvements in bladder pain syndrome for example is yet to be clearly defined, with obvious differences in outcomes between IC/BPS and non-IC/BPS CPPS [110].

Many theories have been suggested for this mode of effect, from restoration of balance between excitatory and inhibitory signals in the pelvic plexus at different spinal levels as well as SNM's modulatory effect on bladder function and in turn pain. Another issue for consideration is the bilateral or multiple sacral root involvement in bladder and pelvic pain disorders, thus S3 stimulation may be insufficient to providing symptomatic relief, and some researchers have demonstrated efficacy of bilateral stimulation [14].

A multitude of studies and researchers are reporting on promising results for SNM in symptomatic management of CPP disorders, demonstrating improvements in pain indices and quality of life measures particularly relating to improvements in sleep, social life and sexual activity [110, 111]. With 10% of patients of IC/BPS reaching a severe stage refractory to conservative and other modes of management, SNM has found an emerging role in the therapeutic void for this condition. Success rates of SNM in IC/BPS have been reported to be high, north of 80% in some series, with apparent and significant objective improvements in pelvic pain and specific interstitial cystitis symptom scores as well as improvements in daytime frequency, nocturia, urinary urgency, and average voided volume [112].

The ICS based on grade C evidence released a level III recommendation that designates SNM as an option for patients who are deemed non-responsive to conservative treatment measures of IC/BPS and non-IC CPPS [4]. However, large randomized controlled trials are lacking, perhaps in part due to the mixed spectrum of CPP disorders, both pathologically and symptomatically, heterogenous patient population, and unclear etiologies, and poorly understood differences in outcomes between the disorders [109, 110, 113].
