Chronic pudendal neuromodulation: expanding available treatment options for refractory urologic symptoms

Chronic pudendal nerve stimulation (CPNS) is a logical alternative particularly in those who fail sacral stimulation. We evaluated symptoms, complications, and satisfaction after CPNS.

We retrospectively reviewed patients having a tined lead placed at the pudendal nerve via the ischial-rectal approach. Demographics, history, complications, and pre-implant voiding diary data were collected. In those responding to CPNS, post-implant symptom changes were measured with the Interstitial Cystitis Symptom and Problem indices (ICSI-PI) and voiding diaries at 3, 6, and 12 months, and a mailed survey.

The majority of 84 patients (78.6% female; age 51.8 ± 16.9 years) had interstitial cystitis/painful bladder syndrome, or overactive bladder. Pudendal response (≥ 50% improvement) occurred in 60/84 (71.4%), however 5 of these chose sacral neuromodulation. Almost all (93.2%) who had previously failed sacral neuromodulation responded to pudendal stimulation. Outcomes were evaluated in 55 continuing on CPNS (median follow up 24.1 months). Seven complications requiring 5 revisions, and 4 other re-operations occurred. Five were explanted. Over time, significant improvements in frequency (P < 0.0001), voided volume (P < 0.0001), incontinence (P < 0.0001), and urgency (P = 0.0019) occurred. ICSI-PI scores significantly improved over 12 months (P < 0.0001). Survey responses indicated that most still had a device (35/40; 87.5%) continuously in use (24/29; 82.8%), and overall bladder, pelvic pain, incontinence, urgency, and frequency symptoms had improved.

CPNS is a reasonable alternative in complex patients refractory to other therapies including sacral neuromodulation. Continued research is needed to fully assess long-term outcomes and identify predictors of success.