The efficacy of laparoscopic surgical treatment of ovarian remnant and ovarian retention syndromes.

STUDY OBJECTIVE: To evaluate the degree of pain relief provided by laparoscopic surgical treatment of ovarian remnant and ovarian retention syndromes. DESIGN: Retrospective analysis (Canadian Task Force classification II-2). SETTING: Academic hospital and affiliated outpatient offices. PATIENTS: A total of 54 patients from 2004 to 2008 who underwent surgical treatment for suspected ovarian remnant syndrome or ovarian retention syndrome. INTERVENTIONS: Oophorectomy. MEASUREMENTS AND MAIN RESULTS: Preoperative and postoperative pain scores were recorded from patients who underwent surgical treatment for either ovarian remnant or ovarian retention syndrome. Data regarding comorbid diagnoses that would contribute to chronic abdominopelvic pain, previous surgical history, surgical complications, and pathology to confirm the preoperative diagnosis were also collected. Pathology confirmed that ovarian tissue was removed in 52 of the 54 patients. Forty percent and 41% of patients with ovarian remnant and ovarian retention, respectively, achieved a 50% reduction of their average pain levels; 50% and 56%, respectively, achieved a 30% reduction in average pain levels. There was not a statistically significant difference in postoperative pain relief between the 2 groups. Cases with ovarian remnant syndrome had more prior surgical procedures (4.8 vs 3.6, p = .049) and were more likely to have a surgical complication (25% vs 3%, p = .03) than cases with ovarian retention syndrome. Patients with a 30% or greater decrease in their pain levels postoperatively were likely to have fewer other diagnoses associated with chronic pain (1.4 ± 1.1 vs 2.1 ± 0.9, p = .009). CONCLUSION: Surgical treatment for ovarian remnant or ovarian retention syndrome is effective but is most effective in patients with no other pain-related diagnoses. Thus, it is important to thoroughly evaluate women with ovarian remnant or ovarian retention syndrome for other pelvic pain-related disorders. In almost all cases, surgery can be done laparoscopically in patients with these syndromes.

Is there a high incidence of hysterectomy and other nonbladder surgeries before and after onset of interstitial cystitis/bladder pain syndrome?

OBJECTIVE: The objective of the study was to compare with controls the incidence of nonbladder pelvic surgeries in the months before and after the onset of interstitial cystitis/bladder pain syndrome (IC/BPS). STUDY DESIGN: The design of the study used an existing database from a retrospective case-control study of 312 incident IC/BPS cases and matched controls plus a longitudinal study of the cases that examined lifetime approximated annual incidence of surgeries with that in the months before and after the onset of IC/BPS. RESULTS: In cases, in the month before the onset of IC/BPS, the approximated annual incidence of nonbladder pelvic surgeries was 15 times higher and of hysterectomy 25 times higher than the incidences of previous years and similarly higher than controls. This rate declined to preindex levels over the first 2 years of IC/BPS. CONCLUSION: There may be a very high incidence of nonbladder surgeries just before IC/BPS onset that decreases to historical levels over the first years of the syndrome.

Abdominal wall nerve injury during laparoscopic gynecologic surgery: incidence, risk factors, and treatment outcomes.

STUDY OBJECTIVE: To determine the incidence and clinical significance of iliohypogastric-ilioinguinal neuropathy from lower abdominal lateral port placement and fascial closure during laparoscopic gynecologic surgery. DESIGN: Retrospective cohort study (Canadian Task Force classification II-2). SETTING: University-based referral center specializing in minimally invasive gynecologic surgery and chronic abdominopelvic pain. PATIENTS: Women who underwent a laparoscopic procedure because of benign gynecologic indications during a 3-year study period from 2008 to 2011. A total of 317 women met study criteria. INTERVENTIONS: Operative laparoscopy using a lateral port in the lower abdomen. Closure of port-site fascial defects was achieved using either a Carter-Thomason or EndoClose suture device. MEASUREMENTS AND MAIN RESULTS: Nerve injury was identified by symptoms, and was confirmed with a nerve block after a positive test for allodynia in the distribution of the iliohypogastric-ilioinguinal nerve. Of 173 cases that did not involve fascial closure of a port-site defect, none were associated with nerve injury. Of 144 cases that involved fascial closure, 7 (4.9%) included nerve injury that resulted in pain requiring treatment (p = .004). In 1 patient, symptoms improved with medical management alone. Six patients required surgical management, and 5 of them had resolution of pain after removal of the fascial suture. There was no statistically significant difference in the incidence of nerve injury between the Carter-Thomason and EndoClose groups (4.7% vs 5.4%; p = .87). CONCLUSIONS: There is an estimated 5% risk of clinically significant postoperative neuropathic pain due to injury of the iliohypogastric-ilioinguinal nerve with fascial closure of laparoscopic incisions in the lower abdomen. Pain seems to be due to suture entrapment of sensory fibers because it is usually resolved by removal of the suture. Prompt recognition and treatment may prevent subsequent development of chronic abdominopelvic pain.

Could chronic pelvic pain be a functional somatic syndrome?

The cause of noncyclical chronic pelvic pain (CPP) in many women is unknown: 30% have no identifiable pelvic pathology, and in those who do the relationship of CPP and the pathology is often unclear. Moreover, epidemiologic studies demonstrate that the common findings of endometriosis and adhesions do not greatly increase the odds of having CPP. CPP and the functional somatic syndromes (fibromyalgia, irritable bowel syndrome, and others) share many characteristics including pain as a prominent symptom and comorbidity. For the functional somatic syndromes, the initial focus of etiologic investigations has been on local mechanisms and then on systemic pathogeneses. We believe that the research trajectories of the functional somatic syndromes and CPP are converging. Their juncture might reveal an important pathologic mechanism for CPP in some women that is primarily outside the pelvis. This observation would open up new areas of exploration and treatment of CPP.

Management of chronic pelvic pain.

Chronic pelvic pain is a complex condition that requires evaluation of the reproductive, gastrointestinal, urologic, musculoskeletal, psychological, and neurological systems. Usually, diagnosis and management entail identifying a network of disorders rather than a single cause of pain with a definitive cure. Only disorders that we commonly encounter in our practice will be discussed in this review.

Use of the Short-Form McGill Pain Questionnaire as a diagnostic tool in women with chronic pelvic pain.

STUDY OBJECTIVE: To estimate the usefulness of the Short-Form McGill Pain Questionnaire (MPQ) pain descriptors in the diagnostic evaluation of chronic pelvic pain. DESIGN: Retrospective cohort study (Canadian Task Force classification II-2). SETTING: University-based center specializing in chronic pelvic pain. PATIENTS: Three hundred thirty-one consecutively evaluated women with chronic pelvic pain who had data sufficient for evaluation. INTERVENTIONS: The relationships between MPQ pain descriptors and subsequent diagnoses were evaluated using odds ratios, sensitivity, specificity, and positive and negative predictive values. MEASUREMENTS AND MAIN RESULTS: The most common diagnoses were endometriosis, interstitial cystitis and painful bladder syndrome, and irritable bowel syndrome. Seventy-one percent of the patients had more than one diagnosis. Relative risks for pain descriptors as diagnostic tools for specific diagnoses were most significant, with "cramping" for endometriosis (4.0), "cramping" for interstitial cystitis and painful bladder syndrome (2.0), "sickening" for irritable bowel syndrome (1.5), and "aching" for abdominal myofascial pain syndrome (4.27). CONCLUSION: Several of the MPQ descriptors had high negative predictive values but not high positive predictive values, which suggests that they have diagnostic usefulness in excluding but not predicting pelvic pain-related diagnoses. This was especially the case with cramping as an MPQ descriptor in women with endometriosis. However, overall the MPQ descriptors were not robust as diagnostic tools, which suggests that inclusion of the MPQ descriptors in the evaluation of women with chronic pelvic pain is of limited diagnostic value.

Pelvic pain and surgeries in women before interstitial cystitis/painful bladder syndrome.

OBJECTIVE: The objective of the study was to compare subjects with interstitial cystitis/painful bladder syndrome (IC/PBS) with controls on prior surgeries. STUDY DESIGN: IC/PBS subjects were compared with matched controls on surgeries and possible surgical indications prior to their index dates. RESULTS: Adjusted for demographic variables, logistic regression showed subjects exceeded controls in surgeries longer than 12 months and less than 1 month before the index date. However, addition of possible surgical indications showed chronic pelvic pain (CPP) to have a strong association with IC/PBS, whereas associations with surgeries were reduced to nonsignificance. CONCLUSION: Although women with IC/PBS were more likely to have experienced prior surgeries than controls, the apparent indications for surgeries, not the surgeries themselves, were stronger risk factors for IC/PBS. In particular, a prior history of CPP had a strong association with IC/PBS. Several features of study design, including extensive medical record review, suggest that prior CPP was not undiagnosed IC/PBS. Further investigation of CPP may yield insight into the pathogenesis of IC/PBS.

The tampon test for vulvodynia treatment outcomes research: reliability, construct validity, and responsiveness.

OBJECTIVE: A standardized tampon insertion and removal test, the Tampon Test provides an alternative to sexual intercourse pain as an outcome measure for vulvodynia research. We report upon the reliability, validity, and responsiveness to change of the Tampon Test as an outcome measure for vulvodynia clinical trials. METHODS: Outcome measures were assessed in women enrolled in the Vulvar Vestibulitis Clinical Trial, a randomized clinical trial of oral desipramine and topical lidocaine effectiveness. Reliability estimates of the Tampon Test using the Kappa statistic evaluated week-to-week measures at baseline. Tampon Test construct and discriminant validity were assessed through correlation with other outcome measures. Patients' ability to regularly perform the Tampon Test was compared with regularity of reporting intercourse pain. RESULTS: During the 2-week baseline phase, women with vulvodynia reported stable mean Tampon Test scores 4.6+/-2.6 (week -2); 4.6+/-2.7 (week -1); and 4.7+/-2.8 (week 0) with moderate week-to-week reliability (weighted Kappa 0.52). Over an 8-week phase of trial intervention, change in the Tampon Test measure significantly correlated to a number of outcome measures, including daily pain (r=0.42), intercourse pain (r=0.35), cotton swab vestibular pain (r=0.38), and the Brief Pain Inventory (r=0.49). Women with vulvodynia study participants performed the Tampon Test 96.3% of the requested time, which was twofold higher adherence than intercourse pain measurement (49.7%). CONCLUSION: The Tampon Test reflects a real life experience that is reliable, with good construct validity as shown by the breadth of correlated outcome measures. The Tampon Test is an appropriate outcome measure for vulvodynia research that can be considered for use as the primary efficacy endpoint in clinical trials of treatments for vulvodynia. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT00276068 LEVEL OF EVIDENCE: II.

Contributions of physical and sexual abuse to women's experiences with chronic pelvic pain.

OBJECTIVE: To examine the roles of physical and sexual abuse in women with chronic pelvic pain using multi-dimensional pain assessment and to compare the chronic pelvic pain experiences of women with physical abuse to those of women with sexual abuse. STUDY DESIGN: Structured questionnaires were used to measure self-reported abuse, pain severity, psychological distress, physical functioning, interpersonalfunctioning, and coping in 63 women attending a tertiary care gynecologic clinic for diagnosis and treatment of chronic pelvic pain. RESULTS: Women with chronic pelvic pain who reported abuse demonstrated significantly more psychological distress than did women who reported no abuse, but there were no differences in pain severity, physical functioning, interpersonal functioning or coping. Women with physical abuse reported more overall psychological distress, depression, anxiety and somatization than women who reported no physical abuse. Women who reported sexual abuse showed more overall psychological distress and anxiety than women who reported no sexual abuse. While physical abuse was more consistently associated with psychological distress than was sexual abuse, both types of abuse were risk factors for distress. CONCLUSION: These results suggest that both physical and sexual abuse are associated with psychological distress in women with chronic pelvic pain but not with other domains of pain experience. Additional research to improve identification and treatment of women with both chronic pelvic pain and abuse is indicated.

Chronic pelvic pain.

Chronic pelvic pain is a common and significant disorder of women. It is estimated to have a prevalence of 3.8% in women. Often the etiology of chronic pelvic pain is not clear, as there are many disorders of the reproductive tract, gastrointestinal system, urological organs, musculoskeletal system, and psychoneurological system that may be associated with chronic pelvic pain. The history and physical examination are crucial in evaluating a woman with chronic pelvic pain and must address all of the possible systems potentially involved in chronic pelvic pain, not just the reproductive system. Laboratory and imaging studies should be selectively utilized, as should laparoscopy. Conscious laparoscopic pain mapping has been proposed as a way to improve information derived from laparoscopic evaluations. Treatment of chronic pelvic pain may consist of two approaches. One is to treat chronic pain itself as a diagnosis, and the other is to treat diseases or disorders that might be a cause of or a contributor to chronic pelvic pain. These two approaches are not mutually exclusive, and in many patients effective therapy is best achieved by using both approaches. Treatment of chronic pain as well as treatment of four of the more common disorders associated with chronic pelvic pain (endometriosis, adhesions, irritable bowel syndrome, and interstitial cystitis) are discussed in this review.

Functional somatic syndromes as risk factors for hysterectomy in early bladder pain syndrome/interstitial cystitis.

OBJECTIVE: We tested the hypothesis that functional somatic syndromes (FSSs) are risk factors for hysterectomy in early bladder pain syndrome/interstitial cystitis (BPS/IC). METHODS: In 312 women with incident BPS/IC, we diagnosed seven pre-BPS/IC syndromes: chronic pelvic pain (CPP), fibromyalgia, chronic fatigue syndrome, irritable bowel syndrome (IBS), sicca syndrome, migraine, and panic disorder. Each was defined as present before 12 months (existing syndrome) or onset within 12 months (new syndrome) prior to BPS/IC onset. Retrospectively, we sought associations between prior hysterectomy and existing FSSs. Prospectively, we studied associations of existing and new syndromes with subsequent hysterectomy. Logistic regression analyses adjusted for age, race, menopause and education. RESULTS: The retrospective study showed prior hysterectomy (N=63) to be associated with existing CPP and the presence of multiple existing FSSs. The prospective study revealed that 30/249 women with a uterus at baseline (12%) underwent hysterectomy in early BPS/IC. This procedure was associated with new CPP (OR 6.0; CI 2.0, 18.2), new IBS (OR 5.4; CI 1.3, 22.3), and ≥3 existing FSSs (OR 3.9; CI 1.1, 13.9). CONCLUSION: Accounting for CPP and IBS, the presence of multiple FSSs (most without pelvic pain) was a separate, independent risk factor for hysterectomy in early BPS/IC. This suggests that patient features in addition to abdominopelvic abnormalities led to this procedure. Until other populations are assessed, a prudent approach to patients who are contemplating hysterectomy (and possibly other surgeries) for pain and who have IBS or numerous FSSs is first to try alternative therapies including treatment of the FSSs.

Before the onset of interstitial cystitis/bladder pain syndrome, the presence of multiple non-bladder syndromes is strongly associated with a history of multiple surgeries.

OBJECTIVE: Certain functional somatic syndromes (FSSs) such as fibromyalgia and irritable bowel syndrome are accompanied by diffuse pain amplification. Women with interstitial cystitis/bladder pain syndrome (IC/BPS) have numerous FSSs, as well as other non-bladder syndromes (NBSs) that are linked to the FSSs. They also report multiple surgeries. Since pain is a common indication for surgery, we tested the hypothesis that NBSs were associated with surgeries. METHODS: We interviewed 312 incident IC/BPS cases and controls on NBSs and number of surgeries before the index date (for cases, IC/BPS onset date). Poisson and logistic regression analyses adjusted for age, race, educational level, and menopause. RESULTS: Number of surgeries increased with number of NBSs in both cases and controls whether chronic pelvic pain (CPP), the only NBS generally accepted as an indication for surgery, was present or not. Logistic regression analysis showed that among cases CPP was the only individual NBS associated with a history of multiple surgeries, and then only modestly [odds ratio (OR) 1.9, confidence intervals (CI) 1.06, 3.2]. By far the strongest association was the number of NBSs. The OR for multiple surgeries increased with number of NBSs: for cases with 4-5 NBSs the OR was 14.1 (1.8, 113) and with 6-9 NBSs, 33.1 (3.9, 279). Controls had fewer syndromes and fewer surgeries and this linkage was less prominent. CONCLUSION: Among IC/BPS cases, the number of NBSs was strongly correlated with the number of surgeries. Understanding temporal relationships will be necessary to explore causal linkages and may modify surgical practice.

Surgical treatment of endometriosis.

In this review, the pitfalls that still exist with the surgical treatment of endometriosisassociatedpelvic pain have been discussed and the best evidence regarding various aspects of surgical techniques have been reviewed. When laparoscopy is performed to evaluate a woman with pelvic pain symptoms, it is important she be counseled that the primary function of the surgery is to confirm the presence (and allow surgical treatment) of endometriosis, and that it is not the penultimate diagnostic modality for her pelvic pain. There are many etiologies of pelvic pain that present with symptoms resembling those of endometriosis-associated pelvic pain that are not diagnosable with laparoscopy, such as interstitial cystitis and irritable bowel syndrome. It is unfortunate that many women are left with the belief that if a laparoscopy fails to provide a diagnosis of a pain generator, then it means there are no diagnoses other than that the "pain is in her head," often disparagingly termed "supratentorial" byclinicians. In fact, the pain-related diagnoses that are amenable to and possibly require a laparoscopy are quite limited, a group of diagnoses that this author terms the "dirty dozen" because there are just 12, and only the first 4 have good evidence to clearly associate them with chronic pelvic pain:1. Endometriosis 2. Ovarian remnant syndrome 3. Pelvic inflammatory disease 4. Tuberculous salpingitis 5. Adhesions 6. Benign cystic mesothelioma 7. Postoperative peritoneal cysts 8. Adnexal cysts (nonendometriotic)9. Chronic ectopic pregnancy 10. Endosalpingiosis 11. Residual accessory ovary 12. Hernias: ventral, inguinal, femoral, spigelian.I would argue that diagnostic laparoscopy in modern gynecology has a limited, if any role, and that when laparoscopy is planned for women with chronic pelvic pain, it should be with a very high suspicion of a diagnosis and with plans to treat the disease operatively. In this era, a negative diagnostic laparoscopy should be a rare event.

Sexuality and reproductive risk factors for interstitial cystitis/painful bladder syndrome in women.

OBJECTIVES: To determine whether interstitial cystitis/painful bladder syndrome (IC/PBS) in women is associated with antecedent sexual and reproductive characteristics. METHODS: By multivariate analyses, 312 incident IC/PBS cases were compared with matched controls for antecedent sexual and reproductive characteristics, adjusted by demographics, previous surgery, and nonbladder syndromes (NBSs), such as chronic pelvic pain, irritable bowel syndrome, and panic disorder. RESULTS: IC/PBS was significantly associated with previous female hormone use, a history of fewer pregnancies (in premenopausal women), and antecedent NBSs, especially when expressed by the number of such syndromes. CONCLUSIONS: Three antecedents to IC/PBS were prominent. Female hormone use was consistent with a pharmacologic effect or as a marker of its indications. A history of fewer pregnancies among premenopausal, but not postmenopausal, women with IC/PBS was consistent with pregnancy postponing the occurrence of IC/PBS, a marker for decisions to avoid pregnancy, or a result of recruitment bias. NBSs, especially the total number experienced by the participant, had the strongest correlation with IC/PBS. This finding suggests that knowledge of the pathogeneses of these NBSs, many of which are functional somatic syndromes, might reveal that of IC/PBS.

Diagnosis and treatment of interstitial cystitis/painful bladder syndrome: a review.

Interstitial cystitis/painful bladder syndrome (IC/PBS) is a chronic bladder disorder characterized by pelvic pain and irritative voiding symptoms. The symptoms of IC/PBS can overlap with such conditions as endometriosis, recurrent urinary tract infection, chronic pelvic pain, overactive bladder, and vulvodynia. The etiology of IC/PBS is likely multifactorial and may involve a defective urothelium, neurogenic upregulation, and mast cell activation. A thorough patient history and physical examination are critical in the differential diagnosis of IC/PBS. Frequent follow-up and patient education are important components of treatment once a condition is diagnosed. A multimodal approach to therapy can provide optimal relief for patients with IC/PBS.

Oral desipramine and topical lidocaine for vulvodynia: a randomized controlled trial.

OBJECTIVE: To estimate the efficacy of common treatments for vulvodynia: topical lidocaine monotherapy, oral desipramine monotherapy, and lidocaine-desipramine combined therapy. METHODS: A 12-week randomized, double-blinded, placebo-controlled trial was conducted on 133 vulvodynia-afflicted women assigned to four treatment arms: placebo tablets-placebo cream, desipramine tablets-placebo cream, placebo tablets-lidocaine cream, and desipramine tablets-lidocaine cream. The tampon test was selected as primary end point using a modified intention-to-treat analysis. Twelve secondary end points were also examined. At completion of the 12-week randomized phase, women were examined "open label" through 52 weeks postrandomization. RESULTS: All treatment arms reported substantial tampon-test pain reduction: 33% reduction placebo cream-placebo tablet, 20% reduction lidocaine cream-placebo tablet, 24% reduction placebo cream-desipramine tablet, and 36% reduction lidocaine cream-desipramine tablet. Compared with placebo, we found no significant difference in tampon-test pain reduction with desipramine (t=0.90; P=.37) or lidocaine (t=1.27; P=.21). Of the remaining 12 outcome measures, only the Index of Sexual Satisfaction, improved with desipramine compared with placebo (t=-2.81; P=.006). During the open-label phase, women undergoing vestibulectomy surgery reported significantly improved pain as measured by cotton swab test and the McGill Pain Scale compared with nonsurgical alternatives. CONCLUSION: Oral desipramine and topical lidocaine, as monotherapy or in combination, failed to reduce vulvodynia pain more than placebo. Placebo or placebo-independent effects are behind the substantial pain improvement seen in all treatment allocations. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT00276068. LEVEL OF EVIDENCE: I.

Endometriosis and mechanisms of pelvic pain.

Endometriosis remains an enigmatic disorder in that the cause, the natural history, and the precise mechanisms by which it causes pain are not completely understood. The pain symptoms most commonly attributed to endometriosis are dysmenorrhea, dyspareunia, and chronic pelvic pain. Pain may be due to nociceptive, inflammatory, or neuropathic mechanisms, and there is evidence that all 3 of these mechanisms are relevant to endometriosis-associated pelvic pain. It is proposed that the clinically observed inconsistencies of the relationships of endometriosis severity and the presence or severity of pain are likely due to variable roles of different pain mechanisms in endometriosis. A better understanding of the roles of nociceptive, inflammatory, and neuropathic pain in endometriosis is likely to improve the treatment of women with endometriosis-associated pelvic pain.

Antecedent nonbladder syndromes in case-control study of interstitial cystitis/painful bladder syndrome.

OBJECTIVES: Probing for clues to the pathogenesis of interstitial cystitis/painful bladder syndrome (IC/PBS), we sought antecedent nonbladder syndromes that distinguished incident IC/PBS cases from matched controls. METHODS: Female incident IC/PBS cases were recruited nationally, and their IC/PBS onset date (index date) was established. The controls were recruited by national random digit dialing and matched to the cases by sex, age, region, and interval between the (assigned) index date and interview. The prevalence of 24 nonbladder syndromes before the index date was assessed, 7 by multiple methods. RESULTS: The cases with IC/PBS had greater antecedent prevalence of 11 syndromes, and 243 of 313 cases (78%) vs 145 of 313 controls (45%) had multiple syndromes (P < .001). Fibromyalgia-chronic widespread pain (FM-CWP), chronic fatigue syndrome, sicca syndrome, and irritable bowel syndrome were associated with each other by pairwise and factor analyses using numerous assumptions. Cases with FM-CWP, chronic fatigue syndrome, sicca syndrome, and/or irritable bowel syndrome (n = 141, 45%) were more likely to have other syndromes (ie, migraine, chronic pelvic pain, depression, and allergy). Three other syndrome clusters were identified; each was associated with this FM-CWP cluster. CONCLUSIONS: Eleven antecedent syndromes were more often diagnosed in those with IC/PBS, and most syndromes appeared in clusters. The most prominent cluster comprised FM-CWP, chronic fatigue syndrome, sicca syndrome, and irritable bowel syndrome; most of the other syndromes and identified clusters were associated with it. Among the hypotheses generated was that some patients with IC/PBS have a systemic syndrome and not one confined to the bladder.

Sacral nerve stimulation: neuromodulation for voiding dysfunction and pain.

Voiding dysfunction, which includes incontinence, retention, and chronic pelvic pain, is a relatively frequent problem that can be difficult to manage. Neuromodulation via stimulation of the sacral nerves has been shown to improve these symptoms, although the exact mechanisms remain elusive. Techniques for nerve stimulation may vary, depending on the disease, location of pain, and the patient's anatomy. In addition to placement of electrodes on the sacral nerve roots, modulation has also been reported by peripheral branches of the sacral nerves including the pudendal and posterior tibial nerves. Newer surgical techniques have significantly decreased the morbidity of the procedures and increased the probability of a successful outcome.