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Antolak SJ. The pudendal syndrome: A photo essay of nerve compression damage visualized at neurolysis in patients with chronic neuropathic pelvic pain. Neurourol Urodyn 2024. [PMID: 39032061 DOI: 10.1002/nau.25555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Revised: 06/07/2024] [Accepted: 07/08/2024] [Indexed: 07/22/2024]
Abstract
AIMS (1) To use intraoperative photographs to visualize and explain pudendal nerve compressions and anatomical variations of compression sites in patients with chronic pelvic pain. (2) To emphasize the diagnostic importance of sensory examination with a safety pin at the six pudendal nerve branches in all patients with chronic pelvic pain; the dorsal nerves (penis or clitoris; the perineal nerves; and the inferior rectal nerves). METHODS Between 2003 and 2014, "definite" pudendal neuropathy was diagnosed by examination and with two neurophysiologic tests. Neurolysis, via a transgluteal approach, was recommended only after 14 weeks of conservative care failed to adequately improve symptoms and validated symptom scores. Photographs of surgical findings were culled for their educational impact. An illustration of each photo clarifies the surgical anatomy. RESULTS The transgluteal incision permits access to pudendal anatomy and compression sites from the subpiriformis area through the interligamentary space and the pudendal canal (Alcock canal). Compressions were acquired or congenital and severity varied significantly. Pinprick sensory testing diagnoses pudendal neuropathy in 92% of both genders. Mid-nerve compression occurred commonly between the sacrotuberous and sacrospinous ligaments less frequently in the Alcock canal, but also at aberrant pathways, for example, between layers of the sacrotuberous ligament; a separate inferior rectal nerve passing through the sacrospinous ligament; at an anomalous lateral pathway posterior to the ischial spine. The results of international surgeons are discussed. CONCLUSIONS Decompression surgery was recommended in approximately 35% of patients in this practice, when pudendal neuropathy (pudendal syndrome), did not respond to two conservative levels of treatment: (1) nerve protection and medications and, (2) a series of three pudendal nerve perineural injections given at 4-week intervals. Significant nerve compression is consistently observed. Pathophysiology includes axonopathy from ischemia and demyelination. Neuropathy is readily diagnosed using a pinprick sensory examination of six pudendal nerve branches. Monitoring with the National Institutes of Health Chronic Prostatitis Symptom Index records cures >13 years.
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Menconi C, Marino F, Bottini C, La Greca G, Gozzo C, Losacco L, Carlucci D, Navarra L, Martellucci J. Evaluation and management of chronic anorectal and pelvic pain syndromes: Italian Society of Colorectal Surgery (SICCR) position statement. Tech Coloproctol 2024; 28:69. [PMID: 38907168 DOI: 10.1007/s10151-024-02943-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Accepted: 05/15/2024] [Indexed: 06/23/2024]
Abstract
Chronic pelvic pain is a hidden issue which needs to involve many different usually uncoordinated specialists. For this reason there is a risk that treatments, in the absence of well-defined pathways, common goals, and terminology, may be poorly effective. The aim of the present paper is to summarize the evidence on anorectal pelvic pain, offering useful evidence-based practice parameters for colorectal surgeons' daily activity. Analysis of chronic anorectal and pelvic pain syndromes, the diagnostic and clinical optimal needs for evaluation, and the innumerable low evidence treatments and therapeutic options currently available suggests that a multimodal individualized management of pain may be the most promising approach. The limited availability of dedicated centers still negatively affects the applicability of these principles.
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Affiliation(s)
- C Menconi
- Proctology and Pelvic Floor Clinical Centre, Cisanello University Hospital, Pisa, Italy
| | - F Marino
- ASL Bari, DSS 3, Bitonto, Bari, Italy
| | - C Bottini
- General Surgery Unit, Materdomini Humanitas Clinical Institute, Castellanza, Varese, Italy
| | - G La Greca
- Coloproctology and Pelvic Floor Unit, IRCSS Policlinico San Donato Hospital, Milan, Italy
| | - C Gozzo
- Radiology Department, Catanese Humanitas Clinical Institute, Catania, Italy
| | - L Losacco
- Surgical Department, Auls 5 Polesana, Rovigo Hospital, Rovigo, Italy
| | - D Carlucci
- Neuroscience Department, Auls 5 Polesana, Rovigo Hospital, Rovigo, Italy
| | - L Navarra
- Surgical Department, AUSL Pescara, Popoli Hospital General Surgery, Pescara, Italy
| | - J Martellucci
- Emergency Surgery, Pelvic Floor Unit, Careggi University Hospital, largo Brambilla 3, 50134, Florence, Italy.
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Levin D, Van Florcke D, Schmitt M, Kendall LK, Patel A, Doan LV, Kirpekar M. Fluoroscopy-Guided Transgluteal Pudendal Nerve Block for Pudendal Neuralgia: A Retrospective Case Series. J Clin Med 2024; 13:2636. [PMID: 38731163 PMCID: PMC11084891 DOI: 10.3390/jcm13092636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Revised: 04/24/2024] [Accepted: 04/27/2024] [Indexed: 05/13/2024] Open
Abstract
Background/Objective: Pudendal neuralgia is a distressing condition that presents with pain in the perineum. While a positive anesthetic pudendal nerve block is one of the essential criteria for diagnosing this condition, this block can also provide a therapeutic effect for those afflicted with pudendal neuralgia. There are multiple ways in which a pudendal nerve block can be performed. The objective of this study is to share our results and follow-up of fluoroscopy-guided transgluteal pudendal nerve blocks. Methods: This is a retrospective case series. Included were 101 patients who met four out of the five Nantes criteria (pain in the anatomical territory of the pudendal nerve, pain worsened by sitting, pain that does not wake the patient up at night, and no objective sensory loss on clinical examination) who did not respond to conservative treatment and subsequently underwent a fluoroscopy-guided transgluteal pudendal nerve block. Therapeutic success was defined as a 30% or greater reduction in pain. Success rates were calculated, and the duration over which that success was sustained was recorded. Results: For achieving at least 30% relief of pain, using worst-case analysis, the success rate at two weeks was 49.4% (95% CI: 38.5%, 60.3%). In addition to pain relief, patients experienced other therapeutic benefits, such as reductions in medication use and improvements in activities of daily living. Conclusions: Fluoroscopy-guided transgluteal pudendal nerve block appears to be effective in patients who have pudendal neuralgia that is resistant to conservative therapy, with good short-term success.
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Affiliation(s)
- Danielle Levin
- Department of Anesthesiology, Perioperative Care & Pain Medicine, New York University Langone Health, New York, NY 10016, USA; (D.V.F.); (L.V.D.)
| | - Daniel Van Florcke
- Department of Anesthesiology, Perioperative Care & Pain Medicine, New York University Langone Health, New York, NY 10016, USA; (D.V.F.); (L.V.D.)
| | - Monika Schmitt
- Department of Physical Medicine and Rehabilitation, New York University Langone Health, New York, NY 10016, USA; (M.S.); (L.K.K.)
| | - Lucinda Kurzava Kendall
- Department of Physical Medicine and Rehabilitation, New York University Langone Health, New York, NY 10016, USA; (M.S.); (L.K.K.)
| | - Alopi Patel
- Department of Anesthesiology, Critical Care & Pain Medicine, Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ 08901, USA;
| | - Lisa V. Doan
- Department of Anesthesiology, Perioperative Care & Pain Medicine, New York University Langone Health, New York, NY 10016, USA; (D.V.F.); (L.V.D.)
| | - Meera Kirpekar
- Department of Anesthesiology, Perioperative Care & Pain Medicine, New York University Langone Health, New York, NY 10016, USA; (D.V.F.); (L.V.D.)
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Chauhan G, Srinivasan SK, Khanduja S. Dorsal Root Ganglion Stimulation Therapy for Refractory Idiopathic Pudendal Neuralgia. Cureus 2023; 15:e34681. [PMID: 36909041 PMCID: PMC9994636 DOI: 10.7759/cureus.34681] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/06/2023] [Indexed: 02/09/2023] Open
Abstract
Dorsal root ganglion stimulation is a relatively new treatment option for chronic pain conditions such as pudendal neuralgia, which is a chronic pain condition affecting the pudendal nerve in the pelvic region. Pudendal neuralgia is a debilitating condition that can significantly affect the patient's quality of life. In dorsal root ganglion stimulation, a small device is implanted that delivers electrical impulses to the dorsal root ganglion to modulate pain signals coming from the pudendal nerve. The procedure is considered investigational and has been investigated in case series and case reports with promising results. However, more research is needed to fully understand its safety and effectiveness. This case report highlights the potential of dorsal root ganglion stimulation as a treatment option for pudendal neuralgia and the need for further research to establish it as a standard treatment option.
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Affiliation(s)
- Gaurav Chauhan
- Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center Presbyterian, Pittsburgh, USA
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Vodegel EV, van Delft KWM, Nuboer CHC, Kowalik CR, Roovers JPWR. Authors' reply: Surgical management of pudendal nerve entrapment after sacrospinous ligament fixation. BJOG 2022; 129:1943. [PMID: 35912888 DOI: 10.1111/1471-0528.17258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Accepted: 06/04/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Eva V Vodegel
- Department of Obstetrics and Gynaecology, Amsterdam Reproduction & Development Research Institute, Amsterdam UMC - Location AMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Kim W M van Delft
- Department of Obstetrics and Gynaecology, Amsterdam Reproduction & Development Research Institute, Amsterdam UMC - Location AMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Charlotte H C Nuboer
- Department of Obstetrics and Gynaecology, Amsterdam Reproduction & Development Research Institute, Amsterdam UMC - Location AMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Claudia R Kowalik
- Department of Obstetrics and Gynaecology, Amsterdam Reproduction & Development Research Institute, Amsterdam UMC - Location AMC, University of Amsterdam, Amsterdam, the Netherlands.,Bergman Clinics - Vrouw, Amsterdam, the Netherlands
| | - Jan-Paul W R Roovers
- Department of Obstetrics and Gynaecology, Amsterdam Reproduction & Development Research Institute, Amsterdam UMC - Location AMC, University of Amsterdam, Amsterdam, the Netherlands.,Bergman Clinics - Vrouw, Amsterdam, the Netherlands
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Levesque A, Bautrant E, Quistrebert V, Valancogne G, Riant T, Beer Gabel M, Leroi AM, Jottard K, Bruyninx L, Amarenco G, Quintas L, Picard P, Vancaillie T, Leveque C, Mohy F, Rioult B, Ploteau S, Labat JJ, Guinet-Lacoste A, Quinio B, Cosson M, Haddad R, Deffieux X, Perrouin-Verbe MA, Garreau C, Robert R. Recommendations on the management of pudendal nerve entrapment syndrome: A formalised expert consensus. Eur J Pain 2021; 26:7-17. [PMID: 34643963 DOI: 10.1002/ejp.1861] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 09/09/2021] [Indexed: 11/06/2022]
Abstract
BACKGROUND Since the development and publication of diagnostic criteria for pudendal nerve entrapment (PNE) syndrome in 2008, no comprehensive work has been published on the clinical knowledge in the management of this condition. The aim of this work was to develop recommendations on the diagnosis and the management of PNE. METHODS The methodology of this study was based on French High Authority for Health Method for the development of good practice and the literature review was based on the PRISMA method. The selected articles have all been evaluated according to the American Society of Interventional Pain Physicians assessment grid. RESULTS The results of the literature review and expert consensus are incorporated into 10 sections to describe diagnosis and management of PNE: (1) diagnosis of PNE, (2) patients advice and precautions, (3) drugs treatments, (4) physiotherapy, (5) transcutaneous electrostimulations (TENS), (6) psychotherapy, (7) injections, (8) surgery, (9) pulsed radiofrequency, and (10) Neuromodulation. The following major points should be noted: (i) the relevance of 4+1 Nantes criteria for diagnosis; (ii) the preference for initial monotherapy with tri-tetracyclics or gabapentinoids; (iii) the lack of effect of opiates, (iv) the likely relevance (pending more controlled studies) of physiotherapy, TENS and cognitive behavioural therapy; (v) the incertitudes (lack of data) regarding corticoid injections, (vi) surgery is a long term effective treatment and (vii) radiofrequency needs a longer follow-up to be currently proposed in this indication. CONCLUSION These recommendations should allow rational and homogeneous management of patients suffering from PNE. They should also allow to shorten the delays of management by directing the primary care. SIGNIFICANCE Pudendal nerve entrapment (PNE) has only been known for about 20 years and its management is heterogeneous from one practitioner to another. This work offers a synthesis of the literature and international experts' opinions on the diagnosis and management of PNE.
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Affiliation(s)
- Amélie Levesque
- Urology Department, Nantes University Hospital, Nantes, France
| | - Eric Bautrant
- Pelvi-Perineal Surgery and Rehabilitation Department, Private Medical Centre "l'Avancée-Clinique Axium", Aix en Provence, France
| | | | | | - Thibault Riant
- Maurice Bensignor Multidisciplinary Pain Center, Centre Catherine de Sienne, Nantes, France
| | - Marc Beer Gabel
- Neurogastroenterology and Pelvic Floor Unit, Sheba Medical Center, Tel Hashomer, Israel
| | | | | | - Luc Bruyninx
- Department of Surgery, Brugmann Hospital, Brussels, Belgium
| | - Gerard Amarenco
- GRC 001, GREEN Groupe de Recherche Clinique en Neuro-Urologie, AP-HP, Hôpital Tenon, Sorbonne Université, Paris, France
| | - Lara Quintas
- Department of Gynecology, Clinical Institute of Gynecology, Obstetrics, and Neonatology, Faculty of Medicine, Barcelona, Spain
| | - Pascale Picard
- Neurology Department, Clermont-Ferrand University Hospital, Inserm, Clermont-Ferrand, France
| | - Thierry Vancaillie
- School of Women and Children, University of New South Wales, Sydney, New South Wales, Australia
| | - Christine Leveque
- Pelvi-Perineal Surgery and Rehabilitation Department, Private Medical Centre "l'Avancée-Clinique Axium", Aix en Provence, France
| | - Frédérique Mohy
- Pain Management Center, University Hospital Felix Guyon, SAINT DENIS, La Reunion, France
| | - Bruno Rioult
- Maurice Bensignor Multidisciplinary Pain Center, Centre Catherine de Sienne, Nantes, France
| | - Stéphane Ploteau
- Department of Gynecology-Obstetrics and Reproductive Medicine, Nantes University Hospital, Nantes, France
| | | | - Amandine Guinet-Lacoste
- Hospices Civils de Lyon, Hôpital Henry Gabrielle, Plate-forme Mouvement et Handicap, Lyon, France
| | - Bertrand Quinio
- Pain Center, Regional University Hospital la Cavale Blanche, Brest, France
| | - Michel Cosson
- Departement of Gynecology, University Hopsital Jeanne De Flandre, Lille, France
| | - Rebecca Haddad
- GRC 001, GREEN Groupe de Recherche Clinique en Neuro-Urologie, AP-HP, Hôpital Tenon, Sorbonne Université, Paris, France
| | - Xavier Deffieux
- Department of Obstetrics and Gynecology, Antoine Beclere Hospital, Assistance Publique Hopitaux de Paris, Clamart University Paris-Saclay, Clamart, France
| | | | | | - Roger Robert
- Maurice Bensignor Multidisciplinary Pain Center, Centre Catherine de Sienne, Nantes, France
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Pudendal Neuralgia: Making Sense of a Complex Condition. CURRENT SEXUAL HEALTH REPORTS 2018. [DOI: 10.1007/s11930-018-0177-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Cvetanovich GL, Saltzman BM, Ukwuani G, Frank RM, Verma NN, Bush-Joseph CA, Nho SJ. Anatomy of the Pudendal Nerve and Other Neural Structures Around the Proximal Hamstring Origin in Males. Arthroscopy 2018; 34:2105-2110. [PMID: 29606539 DOI: 10.1016/j.arthro.2018.02.029] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Revised: 02/07/2018] [Accepted: 02/07/2018] [Indexed: 02/02/2023]
Abstract
PURPOSE To define the anatomy of the pudendal nerve in relationship to the proximal hamstring and other nearby neurological structures during proximal hamstring repair. METHODS Six fresh-frozen human cadaveric hemi-pelvises from male patients ages 64.0 ± 4.1 years were dissected in prone position with hips in 10° flexion to identify the relationship of proximal hamstring origin to surrounding neurologic structures including the pudendal nerve, sciatic nerve, and posterior femoral cutaneous nerve. Two independent observers used digital calipers to measure distances. RESULTS The pudendal nerve emerged at the inferior border of the piriformis muscle 6.3 ± 1.4 cm from the superior aspect of the proximal hamstring origin. It passed the superior border of the sacrotuberous ligament 3.0 ± 0.6 cm from the superior aspect and 3.9 ± 0.7 cm from the medial aspect of the hamstring origin. It crossed the inferior border of the sacrotuberous ligament 3.0 ± 0.4 cm from the superior aspect and 2.7 ± 0.7 cm from the medial aspect of the proximal hamstring origin. The shortest distance from the hamstring origin to the pudendal nerve was 2.6 ± 0.5 cm from the superior aspect and 2.3 ± 0.8 cm from the medial aspect. The shortest distance from the hamstring origin to the pudendal nerve was located deep to the sacrotuberous ligament in all cadavers. The sciatic nerve was an average of 1.1 ± 0.1 cm lateral to the lateral aspect of the proximal hamstring origin. The posterior femoral cutaneous nerve was located between the hamstring origin and the sciatic nerve, 0.7 ± 0.2 cm lateral to the lateral aspect of the proximal hamstring origin. CONCLUSIONS The proximal hamstring origin lies in close proximity to surrounding nerves, including the pudendal, sciatic, and posterior femoral cutaneous nerves. CLINICAL RELEVANCE Knowledge that the pudendal nerve lies 2 to 3 cm superior and medial to the proximal hamstring origin may help to prevent iatrogenic damage during surgical dissection and retraction when performing proximal hamstring repair or deep gluteal space endoscopy.
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Affiliation(s)
- Gregory L Cvetanovich
- Division of Sports Medicine, Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A..
| | - Bryan M Saltzman
- Division of Sports Medicine, Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Gift Ukwuani
- Division of Sports Medicine, Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Rachel M Frank
- Division of Sports Medicine, Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Nikhil N Verma
- Division of Sports Medicine, Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Charles A Bush-Joseph
- Division of Sports Medicine, Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Shane J Nho
- Division of Sports Medicine, Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
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Labat JJ, Riant T, Ploteau S. Authors' reply re: Adding corticosteroids to the pudendal nerve block for pudendal neuralgia: a randomised, double-blind, controlled trial. BJOG 2017; 124:1123. [PMID: 28544720 DOI: 10.1111/1471-0528.14540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/21/2016] [Indexed: 11/30/2022]
Affiliation(s)
- J J Labat
- Centre fédératif de pelvi périnéologie, CHU Nantes, Nantes, France
| | - T Riant
- Centre fédératif de pelvi périnéologie, CHU Nantes, Nantes, France
| | - S Ploteau
- Centre fédératif de pelvi périnéologie, CHU Nantes, Nantes, France
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