Results of pudendal nerve neurolysis-transposition in twelve patients suffering from pudendal neuralgia

Surgical approaches for pudendal nerve entrapment: insights from a systematic review and meta-analysis

BACKGROUND

Pudendal nerve entrapment (PNE) is an underdiagnosed condition affecting a spectrum of pelvic functions, primarily pain, as outlined by Nantes diagnostic criteria. Although numerous surgical decompression techniques are available for its management, consensus on efficacy and safety is lacking. This study conducts a systematic review and meta-analysis to assess the efficacy and complication rates of the main surgical decompression techniques.

METHODS

A comprehensive literature search was conducted in PubMed®, Embase®, Web of Science®, and ClinicalTrails.gov® on 19th of April 2023. Initial screening involved title and abstract evaluation, with subsequent retrieval and assessment of abstracts and full-text articles. Studies assessing pain outcomes before and after surgical release of the pudendal nerve were included. Studies without full-text, focusing on diagnostic methods or with outcomes relating solely to LUTS, digestive symptoms, or sexual dysfunction, were excluded. Risk of bias assessement was conducted using the National Institute of Health (NIH) Study Quality Assessment tool. Studies were categorized based on three surgical techniques: perineal, transgluteal, and laparoscopic transperitoneal. Random-effects meta-analysis with subgroup analysis were used. Meta-regression analyses were conducted to investigate the influence of covariates on the observed outcomes.

RESULTS

Nineteen studies, comprising 810 patients, were included. The overall significant pain relief rate across all techniques was estimated at 0.67 (95% CI 0.54 to 0.78) with considerable heterogeneity (I2 = 80.4%). Subgroup analysis revealed success rate for different techniques: laparoscopic (0.91, 95% CI 0.64 to 0.98), perineal (0.69, 95% CI 0.52 to 0.82), and transgluteal (0.50, 95% CI 0.37 to 0.63). The laparoscopic technique exhibited a complication rate of 16.0%. Meta-regression indicated that patient age and median follow-up significantly influenced outcomes.

CONCLUSION

While comparing surgical techniques is challenging, this meta-analysis highlights important outcome differences. The laparoscopic technique appears most promising for pain improvement. However, the study also emphasizes the need for further robust, long-term research due to significant heterogeneity across studies and prevelent risk of bias. PROSPERO database: CRD42023496564.

Pudendal nerve neurolysis outcomes for urogenital and rectal disorders in patients suffering from pudendal nerve entrapment: A systematic review

PURPOSE

Pudendal neuropathy is an uncommon condition that exhibits several symptoms depending on the site of nerve entrapment. This study aims to evaluate the efficacy of pudendal nerve neurolysis (PNN) in improving lower urinary tract symptoms, anal and/or urinary incontinence, and sexual dysfunctions.

MATERIALS AND METHODS

A systematic literature search was performed on 20 May 2023 using Scopus, PubMed, and Embase. Only English and adult papers were included. Meeting abstracts and preclinical studies were excluded.

RESULTS

Twenty-one papers were accepted, revealing significant findings in the field. The study identified four primary sites of pudendal nerve entrapment (PNE), with the most prevalent location likely being at the level of the Alcock canal. Voiding symptoms are commonly exhibited in patients with PNE. PNN improved both urgency and voiding symptoms, and urinary and anal incontinence but is less effective in cases of long-standing entrapment. Regarding sexual function, the recovery of the somatic afferent pathway results in an improvement in erectile function early after neurolysis. Complete relief of persistent genital arousal disorder occurs in women, although bilateral PNN is necessary to achieve the efficacy. PNN is associated with low-grade complications.

CONCLUSIONS

PNN emerges as a viable option for addressing urinary symptoms, fecal incontinence, erectile dysfunction, and female sexual arousal in patients suffering from PNE with minimal postoperative morbidity.

Pudendal Nerve Neurolysis in Patients Afflicted With Pudendal Nerve Entrapment: A Systematic Review of Surgical Techniques and Their Efficacy

To assess the effectiveness and safety of various techniques of pudendal nerve neurolysis (PNN) in patients with pudendal nerve entrapment (PNE). A comprehensive literature search was conducted on May 20th, 2023, using Scopus, PubMed, and Embase databases. Only studies in English involving adults were accepted, while meeting abstracts and preclinical studies were excluded. A total of 34 papers were included. Transperineal PNN emerged as a promising technique, demonstrating significant potential in alleviating pain, restoring erectile function in males, and improving the resolution of urinary stress incontinence in females. Furthermore, the bilateral approach consistently yielded positive outcomes in addressing urinary symptoms. The transgluteal technique appeared particularly suitable for cases of posterior PNE, situated between the sacrospinous ligament and the lesser sciatic foramen. A progressive amelioration of painful symptoms was observed during follow-up. Minimally invasive PNN is evolving and enables decompression along the entire proximal tract up to the Alcock canal, minimizing the risk of comorbidities. In addition to reducing pudendal neuralgia, robot-assisted and laparoscopic approaches determined a reduction in lower urinary tract symptoms and an improvement in erectile function, though further studies are required to corroborate these findings. PNN emerges as an effective treatment for PNE with minimal morbidity. Therefore, PNN should be tailored according to the site of PNE to enhance functional outcomes and improve patient quality of life.

Origin, course, and distribution of the posterior femoral cutaneous nerve and the spatial relationship among its branches

This study aimed to elucidate the origin, course, and distribution of the branches of the posterior femoral cutaneous nerve, considering the segmental and dorsoventral compositions of the sacral plexus, including the pudendal nerve. The buttocks and thighs of five cadavers were analyzed bilaterally. The branches emerged from the sacral plexus, which was divided dorsally to ventrally into the superior gluteal, inferior gluteal, common peroneal, tibial, and pudendal nerves. It descended lateral to the ischial tuberosity and comprised the thigh, gluteal, and perineal branches. As for the thigh and gluteal branches, the dorsoventral order of those originating from the sacral plexus corresponded to the lateromedial order of their distribution. However, the dorsoventral boundary was displaced at the inferior margin of the gluteus maximus between the thigh and gluteal branches. The perineal branch originated from the ventral branch of the nerve roots. In addition, the pudendal nerve branches, which ran medially to the ischial tuberosity, were distributed in the medial part of the inferior gluteal region. These branches should be distinguished from the gluteal branches; the former should be classified as the medial inferior cluneal nerves and the latter as the lateral ones. Finally, the medial part of the inferior gluteal region was distributed by branches of the dorsal sacral rami, which may correspond to the medial cluneal nerves. Thus, the composition of the posterior femoral cutaneous nerve is considered necessary when considering the dorsoventral relationships of the sacral plexus and boundaries of the dorsal and ventral rami.

Pudendal neuralgia: diagnostics and treatment

The article considers the main causes of the occurrence of pudendal neuralgia. The criteria for diagnosing this state are described in detail. We present basic methods of treatment of pudendal neuralgia starting with comprehensive preservative treatment (physical therapy, medication, blockade), which in most cases are effective. And in case of its ineffectiveness or relapse of the pain syndrome, issues of conduction of pulsed RF-frequency therapy of the nerve are examined. Currently, the possibility of using hyaluronic acid preparations, botulinum toxin for the treatment of sexual neuropathy, as well as cryoanalgesia is being studying. The surgical decompression of the sexual nerve is possible in case of inefficient conservative treatment.

Pudendal nerve entrapment leading to avoidant/restrictive food intake disorder (ARFID): A case report

Avoidant/restrictive food intake disorder (ARFID) is a diagnosis in diagnostic and statistical manual of mental disorders-5 (DSM-5) manifested by persistent failure to meet nutritional and/or energy needs. Pudendal nerve entrapment (PNE) often causes pelvic discomfort in addition to constipation and painful bowel movements. Current literature on ARFID is sparse and focuses on the pediatric and adolescent population. No association between PNE and ARFID has been described. We present a case of ARFID in an adult male with PNE resulting from subsequent scarring from testicular cancer surgery. The patient's gastrointestinal symptoms due to PNE caused significant food avoidance and restriction subsequently leading to severe malnourishment. Clinicians should be aware that distressing gastrointestinal symptoms arising from a secondary disease process such as PNE might lead to dietary restriction and food aversion. More research is needed for proper screening, detection, and treatment of ARFID. © 2016 Wiley Periodicals, Inc. (Int J Eat Disord 2017; 50:84-87).

Sacrotuberous Ligament Healing following Surgical Division during Transgluteal Pudendal Nerve Decompression: A 3-Tesla MR Neurography Study

Pelvic pain due to chronic pudendal nerve (PN) compression, when treated surgically, is approached with a transgluteal division of the sacrotuberous ligament (STL). Controversy exists as to whether the STL heals spontaneously or requires grafting. Therefore, the aim of this study was to determine how surgically divided and unrepaired STL heal. A retrospective evaluation of 10 patients who had high spatial resolution 3-Tesla magnetic resonance imaging (3T MRI) exams of the pelvis was done using an IRB-approved protocol. Each patient was referred for residual pelvic pain after a transgluteal STL division for chronic pudendal nerve pain. Of the 10 patients, 8 had the STL divided and not repaired, while 2 had the STL divided and reconstructed with an allograft tendon. Of the 8 that were left unrepaired, 6 had bilateral surgery. Outcome variables included STL integrity and thickness. Normative data for the STL were obtained through a control group of 20 subjects. STL integrity and thickness were measured directly on 3 T MR Neurography images, by two independent Radiologists. The integrity and thickness of the post-surgical STL was evaluated 39 months (range, 9-55) after surgery. Comparison was made with the native contra-lateral STL in those who had unilateral STL division, and with normal, non-divided STL of subjects of the control group. The normal STL measured 3 mm (minimum and maximum of absolute STL thickness, 2-3 mm). All post-operative STL were found to be continuous regardless of the surgical technique used. Measured at level of Alcock's canal in the same plane as the obturator internus tendon posterior to the ischium, the mean anteroposterior STL diameter was 5 mm (range, 4-5 mm) in the group of prior STL division without repair and 8 mm (range, 8-9 mm) in the group with the STL reconstructed with grafts (p<0.05). The group of healed STLs were significantly thicker than the normal STL (p<0.05). We conclude that a surgically divided STL will heal spontaneously and will be significantly thicker after healing.

Successful treatment of pudendal neuralgia with tricolumn spinal cord stimulation: case report

BACKGROUND AND IMPORTANCE

There is large variation in the success of decompressive surgery for pudendal neuralgia (PN), the most chronic, disabling form of perineal pain. We attempt to determine whether spinal cord stimulation using new-generation multicolumn leads could form part of the treatment algorithm for refractory PN.

CLINICAL PRESENTATION

A man with PN that was unresponsive to conventional treatment demonstrated a neuropathic component and had a negative response to nerve infiltrations (so he was not indicated for decompressive surgery) and a positive response to perianal transcutaneous electrical nerve stimulation and was implanted with a 16-contact surgical lead at the level of conus medullaris, allowing multicolumn stimulation. Using transverse combinations, it was possible to obtain 100% paresthesia over the perineal area without unwanted dorsal root stimulation. Perineal and radicular pain was successfully relieved for up to 12 months (80% and 60% reduction in the visual analogue scale scores, respectively), with an improvement in all quality of life domains and a reduction in drug consumption.

CONCLUSION

Spinal cord stimulation using a 16-contact lead may be a viable therapeutic option for patients with refractory PN for whom decompressive surgery is contraindicated.

Gynecologic management of neuropathic pain

Obstetrician/gynecologists often are the initial management clinicians for pelvic neuropathic pain. Although treatment may require comprehensive team management and consultation with other specialists, there are a few critical and basic steps that can be performed during an office visit that offer the opportunity to improve quality of life significantly in this patient population. A key first step is a thorough clinical examination to map the pain site physically and to identify potentially involved nerves. Only limited evidence exists about how best to manage neuropathic pain; generally, a combination of surgical, manipulative, or pharmacologic methods should be considered. Experimental methods to characterize more precisely the nature of the nerve dysfunction exist to diagnose and treat neuropathic pain; however, additional scientific evidence is needed to recommend these options unanimously. In the meantime, an approach that was adopted from guidelines of the International Association for the Study of Pain has been tailored for gynecologic pain.

Diagnosis and treatment of pudendal nerve entrapment syndrome subtypes: imaging, injections, and minimal access surgery

Object

To improve diagnostic accuracy and achieve high levels of treatment success in patients with pudendal nerve entrapment (PNE) syndromes, the author of this study applied advanced technology diagnostics in distinguishing the various syndrome types according to the different entrapment locations and evaluated new minimal access surgical techniques to treat each subtype.

Methods

Two hundred cases were prospectively evaluated using a standardized set of patient-completed functional and symptom assessments, a collection of new physical examination maneuvers, MR neurography, open MR image–guided injections, intraoperative neurophysiology, minimal access surgery, and formal outcome assessment with the Oswestry Disability Index, pain diagrams, and analog pain scales.

Results

Four primary types of PNE syndromes were identified based on the different locations of entrapment: Type I, entrapment at the exit of the greater sciatic notch in concert with piriformis muscle spasm; Type II, entrapment at the level of the ischial spine, sacrotuberous ligament, and lesser sciatic notch entrance; Type III, entrapment in association with obturator internus muscle spasm at the entrance of the Alcock canal; and Type IV, distal entrapment of terminal branches. The application of new, targeted minimal access surgical techniques led to sustained good to excellent outcomes (50–100% improvement in the pain score or functional score) in 87% of patients. Most of these patients obtained most of their improvement within 4 weeks of surgery, although some continued to experience progressive improvements up to 12 months after surgery.

Conclusions

The application of advanced diagnostics to categorize PNE syndrome origins into 4 major subtypes and the subsequent treatment of each subtype with a tailored strategy greatly improved therapeutic outcomes as compared with those reported when only a single treatment paradigm was applied to all patients.

Postoperative complications after procedure for prolapsed hemorrhoids (PPH) and stapled transanal rectal resection (STARR) procedures

Procedure for prolapsing hemorrhoids (PPH) and stapled transanal rectal resection for obstructed defecation (STARR) carry low postoperative pain, but may be followed by unusual and severe postoperative complications. This review deals with the pathogenesis, prevention and treatment of adverse events that may occasionally be life threatening. PPH and STARR carry the expected morbidity following anorectal surgery, such as bleeding, strictures and fecal incontinence. Complications that are particular to these stapled procedures are rectovaginal fistula, chronic proctalgia, total rectal obliteration, rectal wall hematoma and perforation with pelvic sepsis often requiring a diverting stoma. A higher complication rate and worse results are expected after PPH for fourth-degree piles. Enterocele and anismus are contraindications to PPH and STARR and both operations should be used with caution in patients with weak sphincters. In conclusion, complications after PPH and STARR are not infrequent and may be difficult to manage. However, if performed in selected cases by skilled specialists aware of the risks and associated diseases, some complications may be prevented.

Postoperative complications after procedure for prolapsed hemorrhoids (PPH) and stapled transanal rectal resection (STARR) procedures

Procedure for prolapsing hemorrhoids (PPH) and stapled transanal rectal resection for obstructed defecation (STARR) carry low postoperative pain, but may be followed by unusual and severe postoperative complications. This review deals with the pathogenesis, prevention and treatment of adverse events that may occasionally be life threatening. PPH and STARR carry the expected morbidity following anorectal surgery, such as bleeding, strictures and fecal incontinence. Complications that are particular to these stapled procedures are rectovaginal fistula, chronic proctalgia, total rectal obliteration, rectal wall hematoma and perforation with pelvic sepsis often requiring a diverting stoma. A higher complication rate and worse results are expected after PPH for fourth-degree piles. Enterocele and anismus are contraindications to PPH and STARR and both operations should be used with caution in patients with weak sphincters. In conclusion, complications after PPH and STARR are not infrequent and may be difficult to manage. However, if performed in selected cases by skilled specialists aware of the risks and associated diseases, some complications may be prevented.

Postoperative complications after procedure for prolapsed hemorrhoids (PPH) and stapled transanal rectal resection (STARR) procedures

Procedure for prolapsing hemorrhoids (PPH) and stapled transanal rectal resection for obstructed defecation (STARR) carry low postoperative pain, but may be followed by unusual and severe postoperative complications. This review deals with the pathogenesis, prevention and treatment of adverse events that may occasionally be life threatening. PPH and STARR carry the expected morbidity following anorectal surgery, such as bleeding, strictures and fecal incontinence. Complications that are particular to these stapled procedures are rectovaginal fistula, chronic proctalgia, total rectal obliteration, rectal wall hematoma and perforation with pelvic sepsis often requiring a diverting stoma. A higher complication rate and worse results are expected after PPH for fourth-degree piles. Enterocele and anismus are contraindications to PPH and STARR and both operations should be used with caution in patients with weak sphincters. In conclusion, complications after PPH and STARR are not infrequent and may be difficult to manage. However, if performed in selected cases by skilled specialists aware of the risks and associated diseases, some complications may be prevented.

Traditional therapy for chronic pelvic pain does not work: what do we do now?

The dilemma of managing patients with chronic pelvic pain syndromes continues to frustrate physicians confronted with these complaints. Multiple diagnoses traditionally label this condition in men and women and, typically, implicate a pelvic-organ system when, in fact, very little objective evidence for a pathophysiologic process exists. Traditional therapies, consisting of antibiotics, anti-inflammatories, and muscle relaxants, simply do not work, and their lack of efficacy compared with placebo has been documented by randomized clinical trials in the US that were sponsored by the NIH. What do we do now? This review article attempts to describe the clinical efforts of several investigators and to put their patients' outcomes in perspective, and thereby suggest alternative therapies to help these patients.

Anatomical and surgical considerations of the sacrotuberous ligament and its relevance in pudendal nerve entrapment syndrome

In view of the paucity of literature, this study was undertaken to reappraise the gross anatomy of the sacrotuberous ligament (STL), with the objective of providing an accurate anatomical basis for clinical conditions involving the STL. We studied the gross anatomy of the STL in 50 formalin fixed cadavers (100 sides) during the period of 2004-2005. All specimens exhibited an STL with a ligamentous part and (87%) of specimens exhibited a membranous (falciform) segment, which extended towards the ischioanal fossa. The variations of the falciform extensions were classified into three types. In Type I (69%), the falciform process extended towards and along the ischial ramus to terminate at the obturator fascia. In Type II (108%), the falciform process extended along the ischial ramus, fused with the obturator fascia and continued towards the ischioanal fossa. In addition, the medial border of the falciform process descended to fuse with the anococcygeal ligament, forming a continuous membrane. Lastly, in Type III (13%), the falciform process of the STL was absent. The above mentioned data could have an important implication to the understanding of the relationship between the pudendal nerve and the sacrotuberous ligament and their relevance to pudendal nerve entrapment syndrome.

Anatomy of pudendal nerve at urogenital diaphragm--new critical site for nerve entrapment

OBJECTIVES

To investigate the relations of the pudendal nerve in this complex anatomic region and determine possible entrapment sites that are accessible for surgical decompression. Entrapment neuropathies of the pudendal nerve are an uncommon and, therefore, often overlooked or misdiagnosed clinical entity. The detailed relations of this nerve as it exits the pelvis through the urogenital diaphragm and enters the mobile part of the penis have not yet been studied.

METHODS

Detailed anatomic dissections were performed in 10 formalin preserved hemipelves under 3.5x loupe magnification. The pudendal nerve was dissected from the entrance into the Alcock canal to the dorsum of the penis. The branching pattern of the nerve and its topographic relationship were recorded and photographs taken.

RESULTS

The anatomic dissections revealed that the pudendal nerve passes through a tight osteofibrotic canal just distal to the urogenital diaphragm at the entrance to the base of the penis. This canal is, in part, formed by the inferior ramus of the pubic bone, the suspensory ligament of the penis, and the ischiocavernous body. In two specimens, a fusiform pseudoneuromatous thickening was found.

CONCLUSIONS

The pudendal nerve is susceptible to compression at the passage from the Alcock canal to the dorsum of the penis. Individuals exposed to repetitive mechanical irritation in this region are especially endangered. Diabetic patients with peripheral neuropathy can have additional compression neuropathy with decreased penile sensibility and will benefit from decompression of the pudendal nerve.

Pudendal neuralgia, a severe pain syndrome

OBJECTIVE

To describe the clinical and electrodiagnostic findings, therapies, and outcomes of patients with pudendal neuralgia.

STUDY DESIGN

A retrospective, descriptive study of 64 patients from March 19 to December 22, 2003.

RESULTS

Clinical findings included pain along nerve distribution (64, 100%), pain aggravated by sitting (62, 97%), pain relieved by standing or lying (57, 89%), and misdiagnosis (53, 83%). Neurophysiologic findings were normal (23, 35%), demyelination (17, 26%), axonal loss (5, 7.5%), and demyelination with axonal loss (21, 32%). Therapies were conservative (64, 100%), nerve injection (38, 59%), neuromodulation (2, 3%), and decompression surgery (10, 15%). Slight or moderate pain improvement with therapies included conservative (64, 100%), nerve injection (12, 31%), neuromodulation (2, 100%), and decompression (6, 60%).

CONCLUSION

Pudendal neuralgia is poorly recognized and poorly treated. Improvement is gained with conservative therapy. Injections and decompression benefit one half and one third of patients, respectively. Neuromodulation needs further evaluation.

Botulinum Toxin a Injection of the Obturator Internus Muscle for Chronic Perineal Pain

Chronic perineal pain is often a difficult condition to manage. Current treatments include pudendal nerve injections and pudendal nerve release surgery. The obturator internus muscle has a close relationship to the pudendal nerve and might be a potential target for therapeutic intervention.

PERSPECTIVE

A case is presented of refractory perineal pain that was successfully treated by injecting the obturator internus muscle with botulinum toxin A.

Pudendal nerve decompression in perineology: a case series

BACKGROUND

Perineodynia (vulvodynia, perineal pain, proctalgia), anal and urinary incontinence are the main symptoms of the pudendal canal syndrome (PCS) or entrapment of the pudendal nerve. The first aim of this study was to evaluate the effect of bilateral pudendal nerve decompression (PND) on the symptoms of the PCS, on three clinical signs (abnormal sensibility, painful Alcock's canal, painful "skin rolling test") and on two neurophysiological tests: electromyography (EMG) and pudendal nerve terminal motor latencies (PNTML). The second aim was to study the clinical value of the aforementioned clinical signs in the diagnosis of PCS.

METHODS

In this retrospective analysis, the studied sample comprised 74 female patients who underwent a bilateral PND between 1995 and 2002. To accomplish the first aim, the patients sample was compared before and at least one year after surgery by means of descriptive statistics and hypothesis testing. The second aim was achieved by means of a statistical comparison between the patient's group before the operation and a control group of 82 women without any of the following signs: prolapse, anal incontinence, perineodynia, dyschesia and history of pelvi-perineal surgery.

RESULTS

When bilateral PND was the only procedure done to treat the symptoms, the cure rates of perineodynia, anal incontinence and urinary incontinence were 8/14, 4/5 and 3/5, respectively. The frequency of the three clinical signs was significantly reduced. There was a significant reduction of anal and perineal PNTML and a significant increase of anal richness on EMG. The Odd Ratio of the three clinical signs in the diagnosis of PCS was 16,97 (95% CI = 4,68 - 61,51).

CONCLUSION

This study suggests that bilateral PND can treat perineodynia, anal and urinary incontinence. The three clinical signs of PCS seem to be efficient to suspect this diagnosis. There is a need for further studies to confirm these preliminary results.

Douleurs anopérinéales chroniques, diagnostic et stratégie d’exploration

Chronic anoperineal pain may result from diverse causes; a precise and painstaking diagnostic approach is necessary to avoid inappropriate treatments which may aggravate the situation. Advances in imaging and neurophysiologic testing have improved the ability to diagnose and differentiate coccydynia, pudendal neuralgia, and the pyriformis muscle syndrome. Other etiologies including anismus, the descending perineum syndrome, and the levator ani syndrome are discussed as well as psychologic ans somatic interactions.

Chronic Prostatitis/Chronic Pelvic Pain Syndrome: Is There a Role for Local Drug Infiltration Therapy?

The clinical syndrome of chronic prostatitis ranges from well-defined chronic bacterial infections to poorly defined chronic pelvic pain syndrome (CPPS), previously referred to as "prostatodynia" or "abacterial prostatitis." Faced with the obscure nature of the disease, its protracted course, and the poor response to oral medication, urologists have considered alternative routes of drug administration. We review the indications and outcomes of local drug infiltration (intraprostatic antibiotic and zinc, intrasphincteric botulinum toxin A, pudendal nerve blocks) and discuss their potential use and benefit in the treatment of chronic prostatitis syndromes.

Management of vulvar pain

Vulvodynia is a frequently used medical term that literally means "vulvar pain". Therefore, vulvodynia is a symptom, not a disease. The term itself indicates a variety of unpleasant chronic vulvar sensations, including burning, rawness, soreness, irritation, sensitivity, and formication. This may or may not include dyspareunia. Primary vulvodynia occurs when these sensory disturbances occur in the absence of observable dermatologic disease or vulvovaginal infection. There are several causes for this, including neuropathy, referred pain, and pelvic floor muscle dysfunction. For the purist, it is the patient in whom there is no observable reason for vulvar pain who represents the true case of vulvodynia. However, vulvodynia can also occur secondarily as a symptom of vulvar skin disease. Restricting the present paper to patients without objective signs leaves out all the important conditions which come into the differential diagnosis of vulvar pain which should be ruled out first. The first step in managing vulvodynia is making an accurate diagnosis of its cause. The present review summarizes the diagnosis and management of the chronic dermatologic diseases which may cause primary and secondary vulvodynia. The etiology of primary vulvodynia is much more poorly understood than secondary vulvodynia, and treatment of some aspects remains controversial.

New, simple, ultrasound-guided infiltration of the pudendal nerve: ultrasonographic technique

PURPOSE

Anesthetic infiltration of the pudendal nerve at the ischial spine can relieve perineal pain in cases of compression or distention. The aim of our study was to look for a real-time, visually controlled infiltration technique using ultrasound.

METHODS

Fifty-three volunteers were examined in a prone position using a 3.5-MHz curved-array probe in color-coded Doppler mode. The deep gluteal region was scanned in two perpendicular planes, longitudinal and transverse to the internal pudendal artery.

RESULTS

On the transverse planes the ischial spine, the sacrospinous ligament, and the internal pudendal artery were depicted in all but two cases. In 47.2 percent of the cases one trunk of the pudendal nerve was detected directly. Nerves consisting of more than one trunk were not found. The thickness of the nerve ranged between 3.5 and 7 mm.

CONCLUSIONS

In almost one-half of the cases a direct ultrasound-guided infiltration of the pudendal nerve is possible. In the remaining cases the nerve can be detected and blocked indirectly, using the ischial spine or the internal pudendal artery as a landmark.

Transanally injected triamcinolone acetonide in levator syndrome

PURPOSE

Several treatments are used for the treatment of levator syndrome, such as rectal massage, biofeedback, and galvanic stimulation. But their effects are inconsistent, and multiple treatment sessions are usually required. Triamcinolone acetonide and lidocaine mixture was injected locally into the tenderest point in levator syndrome under the hypothesis that levator syndrome is caused by tendinitis of pelvic floor musculature.

METHODS

A mixture of 40 mg of triamcinolone acetonide and 1 ml of 2 percent lidocaine was injected into the tenderest point transanally in 104 patients (33 males; mean age, 51 years) with levator syndrome from December 1996 to May 1998 at Daehang Clinic. Additional injections were repeated at two-week intervals to a maximum of three injections in cases of poor response. Follow-up was performed prospectively concerning patient's perception of pain level using a visual analog scale. Depending on the response, the patients were classified into four groups: pain-free, good, fair, and no response. More than 50 percent pain reduction was classified as "good," and less than 49 percent reduction as "fair."

RESULTS

The injection regions, where the tenderest points were identified on digital rectal compression, were left anterior anal canal in 71.2 percent of patients, right anterior in 3.8 percent of patients, and posterior in 25 percent of patients. The results of treatment were as follows: at three months after injection, response was classified as pain-free in 36.8 percent of patients, good in 35 percent of patients, fair in 19.5 percent of patients, and no response in 8.7 percent of patients; at six months the response was pain-free in 30.1 percent of patients, good in 46.5 percent of patients, fair in 18.2 percent of patients, and no response in 5.2 percent of patients. Most patients, except 8.7 percent at three months and 5.2 percent at six months, experienced treatment benefits. There were no complications during the follow-up periods.

CONCLUSION

Transanal injection of triamcinolone acetonide and lidocaine mixture into the tenderest point is such a simple, safe, and very effective modality that it can be recommended as a primary therapy for levator syndrome.