Neuromodulatory approaches to chronic pelvic pain and coccygodynia.

Intractable chronic pelvic pain (CPP) despite a multidisciplinary approach is challenging to treat. Every structure in the abdomen and/or pelvis could have a role in the etiology of CPP. Management of chronic pelvic pain may require a combination of interventions, including pharmacological, physical and psychological therapy. Interventions suggested to date include nerve blocks (ilioinguinal, iliohypogastric, genitofemoral, hypogastric, presacral) and trigger point injections, radiofrequency treatments, spinal cord stimulation (SCS), sacral root stimulation, sacral magnetic stimulation and sacral stimulation via tibial nerve. Peripheral nerve stimulation (PNS) has been particularly successful in the treatment of mononeuropathies. Indications for targeted stimulation include localised pain in non dermatomal distribution. Herein, the epicenter of the site of pain (target) is stimulated either transcutaneously or percutaneously or via permanent neuromodulating implant. Targeted and PNS probably are underused treatment modalities given the simplicity of the technique. The introduction of a stimulating electrode directly to the center of peripherally affected, painful areas, thereby bypassing the spinal cord and peripheral nerves is a novel simple procedure with effectiveness in the control of intractable neuropathic pain. Development of newer devices and miniaturization of electrodes will play a role in refinement and further simplification of subcutaneous neuromodulation.