Approche symptomatique des douleurs pudendales chroniques

Could Horse Gait and Induced Pelvic Dynamic Loads in Female Equestrians Be a Risk Factor in Pudendal Neuralgia?

Pudendal Neuralgia (PN) is a rare, debilitating disease caused by damage to the pudendal nerve, which innervates the anus, rectum, perineum, lower urinary tract, and genitalia. Although its etiology remains scientifically unknown, a number of sports practices, including horse-riding, are reported as triggering and/or aggravating factors. The present work summarizes the experimental measurements of the contact pressure at the interface between the rider and saddle, for a population of 12 experienced female riders. These tests reveal that dynamic horseback-riding leads to high levels of peak pressures in the perineal region, which confirms that the practice of equine sports may cause neuropathologies such as PN. All collected data will be used as boundary conditions in a future numerical 3D model aimed at locating the possible areas of pudendal nerve crushing.

The Clinical Efficacy of High-Voltage Long-Duration Pulsed Radiofrequency Treatment in Pudendal Neuralgia: A Retrospective Study

BACKGROUND

Patients with pudendal neuralgia (PN) experience long-lasting chronic pain, hyperalgesia, and comorbid emotional disorders, such as depression and anxiety. Treatment via conventional pulsed radiofrequency (PRF) current carries a significantly high rate of failure.

OBJECTIVE

To determine the safety and clinical efficacy of high-voltage, long-duration PRF application to the pudendal nerve in patients with PN.

STUDY DESIGN

Observational retrospective design, self before-after controlled clinical trial.

MATERIALS AND METHODS

We analyzed the records of 70 patients of our hospital with diagnosed PN. Treatment consisted of PRF application to the pudendal nerve, using computed tomography guidance to target the pudendal nerve at the level of the ischial spine or ischial tuberosity of the affected side. PRF was applied with the following parameters: temperature 42 °C, frequency 2 Hz, pulse width 20 ms, field intensity ramped gradually from 40 to 90 V, duration 900 sec. The therapeutic effect was evaluated by collecting patient scores for the visual analog scale (VAS), SF-36 health survey questionnaire (SF-36), and patient health questionnaire (PHQ-9) before treatment and at 1-, 4-, and 12-week follow-ups after PRF treatment. Data were analyzed by paired t-test with p < 0.05 considered to be statistically significant.

RESULTS

VAS, SF-36, and PHQ-9 scores at 1, 4, and 12 weeks after high-voltage long-duration PRF treatment were significantly improved relative to their respective pretreatment baseline scores (p < 0.05 for all). The effective rate at 12 weeks after high-voltage long-duration PRF was up to 88.6%.

LIMITATIONS

A small sample size and lack of a control group.

CONCLUSIONS

High-voltage long-duration PRF provided significant short-term (at least 12 weeks) pain relief to most patients with PN; it also improved subjective measures of depression and quality of life over the same duration of time.

Advances in the therapeutic approach of pudendal neuralgia: a systematic review

CONTEXT

Although pudendal neuralgia (PN) has received growing interest over the last few years, diagnosis remains difficult, and many different therapeutic approaches can be considered.

OBJECTIVES

This article aims to provide an overview of the possible treatments of PN and investigate their efficacies.

METHODS

Utilizing PubMed and ScienceDirect databases, a systematic review was carried out and allowed identification of studies involving patients with PN, as defined by Nantes criteria, and their associated treatments. Relevant data were manually reported.

RESULTS

Twenty-eight articles were selected, totaling 1,013 patients (mean age, 49 years) and six different types of interventions. Clinical outcomes, most frequently quantified utilizing the Visual Analog Scale (VAS), vary greatly with both the therapy and time after intervention (from 100 to <10%). However, neither peri nor postoperative serious complications (grade > II of Clavien-Dindo classification) are reported. Although surgery seems to provide a higher proportion of long-term benefits, identifying the most efficient therapeutic approach is made impossible by the multitude of outcome measurements and follow-up frequencies. It should also be noted that literature is sparse regarding randomized controlled trials with long-term follow-up.

CONCLUSIONS

Although there are a number of modalities utilized for the treatment of PN, there are no current recommendations based on treatment efficacies. This seems to be largely in part caused by the lack of standardization in outcome quantification. Future research in this field should focus on prospective cohort studies with high levels of evidence, aimed at assessing the long-term, if not permanent, benefits of available therapies.

Clinical effect of computed guided pudendal nerve block for patients with premature ejaculation: a pilot study

Background: Premature ejaculation has a complex etiology, and its pathophysiology is still unclear, with penile hypersensitivity being the most accepted hypothesis. The aim was to investigate the efficacy and safety of a computed tomography-guided pudendal nerve block at the level of the sacrospinous ligament and the Alcock's canal in patients with premature ejaculation refractory to conventional pharmacological treatment.Methods: This is a prospective pilot study involving five patients suffering from premature ejaculation refractory to standard treatment and clinical features of pudendal nerve entrapment. A CT-guided infiltration of ropivacaine and methylprednisone was done at the levels of sacrospinous ligament and Alcock's canal. Intra-vaginal ejaculatory latency time (IELT) was recorded several times for each patient before and after infiltration. International Index of Erectile Function (IIEF-5), Premature Ejaculation Diagnostic Tool (PEDT) and Sexual Quality of Life-Male version (SQoL-M) questionnaire were also evaluated before and after infiltration.Results: Overall IELT differed significantly before and after treatment (21.94 vs 215.42 s; p = 0.039). IIEF-5, PEDT and SQoL-M also differed significantly before and after treatment. No complications for the CT-guided infiltration were recorded.Conclusion: CT-guided pudendal nerve block at the sacrospinous ligament and the Alcock's canal was effective in improving premature ejaculation. Therefore, pudendal nerve entrapment may be a curable cause of sensory premature ejaculation.

[Not Available]

Le syndrome du canal d’Alcock – ou névralgie pudendale – est lié à la compression chronique du nerf pudendal dans la fossette ischio rectale ou au niveau du ligament sacroépineux. Le diagnostic du syndrome d’Alcock est surtout clinique. Les examens complémentaires sont dominés par les explorations électrophysiologiques et le test de bloc anesthésique. Le diagnostic repose sur des critères bien précis, soit les critères de Nantes. La prise en charge doit être globale, comprenant un traitement médicamenteux, des infiltrations, des techniques de neuromodulation, et dans les cas graves ou résistants, un traitement chirurgical qui consiste à libérer le nerf pudendal. Les névralgies pudendales peuvent être rencontrées après traitement d’une incontinence urinaire d’effort par bandelettes sous-urétrales (TVT). Ce syndrome motive des consultations en urologie, car la douleur intéresse le territoire du périnée et des organes génitaux. Des signes urinaires peuvent aussi accompagner cette douleur. Il est donc judicieux de connaître cette pathologie.

[Painful ejaculation]

OBJECTIVE

To clarify definition, epidemiology, diagnosis, evaluation, etiologies and treatment of painful ejaculation (PE).

MATERIAL AND METHODS

Review of the literature performed by searching the Medline database using keywords ejaculation, orgasm, pain, pelvic pain, sexual behavior.

RESULTS

PE is a pelviperineal pain caused by ejaculation or orgasm. Its prevalence rate is between 1 and 4% amongst the general population. Mainly located in the penis, pain usually lasts less than 5 minutes. Assessment is clinical and there is no level of evidence about the strategy of complementary investigations. Benign prostatic hyperplasia, chronic pelvic pain syndrome, radical prostatectomy, prostate brachytherapy and some antidepressant medications are the best estimated etiologies found in the literature. A link between urogenital infections and PE is likely but not clearly established. Alpha-blockers had good therapeutic results in few low level of evidence studies.

CONCLUSION

The assessment of PE is not clearly defined. Some etiologies are known but PE may be a functionnal pain. Only high level of evidence studies would validate the use of the alpha-blockers as an efficient therapeutic option.

CT-guided percutaneous pulse-dose radiofrequency for pudendal neuralgia

PURPOSE

The purpose of our study was to evaluate the efficacy of computed tomography (CT)-guided percutaneous pulse-dose radiofrequency (PDRF) for the treatment of chronic pain in patients with pudendal neuralgia (PN) unresponsive to conservative approaches.

METHODS

From March 2010 to January 2012, 30 patients with a diagnosis of PN were prospectively enrolled in the study, 18 women and 12 men (mean age 47 years). A 20-gauge cannula with a 10-cm length was placed under CT guide in the pudendal (Alcock's) canal. After the spindle was removed, a radiofrequency needle with a 5-mm active tip was introduced. The appropriate needle placement near the pudendal nerve, without an involvement of the vessels, was confirmed with an injection of 1-2 ml of contrast agent. PDRF was performed with 1,200 pulses at high voltage (45 V) with 20 ms duration followed by 480 ms silent phases.

RESULTS

Twenty-six patients completed the study. Procedural success was achieved in all patients. Mean VAS scores before PDRF was 9 ± 0.7. Patients had a great improvement in pain intensity after 1 week by PDRF (mean VAS scores 3.8 ± 1.7, p < 0.05), with a stabilization of the symptomatology in the following months (mean VAS scores 1.5 ± 1.1 at 6 months by PDRF, p < 0.05) and excellent results after 1 year by the procedure (mean VAS scores 1.9 ± 0.7, p < 0.05).

CONCLUSIONS

In our preliminary experience, CT-guided percutaneous PDRF should be recommended for treatment of PN because we evaluated the tolerability of this procedure with satisfactory and encouraging results.

Pudendal nerve in pelvic bone fractures

INTRODUCTION

Pelvic ring injuries rank among the most serious skeletal injuries. According to published data, pelvic fractures constitute 3-8% of all fractures. There has been a threefold increase in the number of these fractures over the last 10 years. A significant factor determining the choice of the therapeutic procedure, timing and sequence of individual steps, and also the prognosis of the patient with a fractured pelvis, are associated injuries defined as injuries to the organs and anatomical structures found in the pelvic region. Published data describes the incidence of injury to neurogenic structures as ranging between 9 and 21%, to the urogenital tract between 5 and 11%, to the gastrointestinal tract in 3-17% and to the gynecologic organs up to 1%. The pathway of the pudendal nerve may be affected in types B and C fractures where the root fibers emerge from the foramina sacralia and plexus sacralis is formed, on the one hand, and in types A, B and C fractures during the nerve's course alongside the inferior pubic ramus.

MATERIALS AND METHODS

In order to determine the frequency of potential injury to the pudendal nerve, a set of 225 pelvic fractures treated between 2007 and 2009 was assessed; 38 fixed hemipelves were also used to study the length of the course of the pudendal nerve alongside the inferior pubic ramus, on the one hand, and the distances from the symphysis pubica at the crossing of the branches of the n. pudendus-n. dorsalis penis and the branches for the muscles of the diaphragma urogenitale on the other hand.

CONCLUSION

The work elucidated the selected distances and discuss their possible clinical relevance for evaluation of the seriousness of pelvic fractures from the perspective of late sequelae in the region innervated by the pudendal nerve.

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.

Pelvic floor therapies in chronic pelvic pain syndrome

Chronic pelvic pain syndrome is a poorly understood clinical entity associated with urinary symptoms, pelvic floor dysfunction, and multisystem disorders. Treatment of pelvic floor dysfunction is difficult and often frustrating for the patient as well as for the involved physician. The purpose of this review is to update clinicians on the latest research for the treatment of pelvic floor dysfunction in relation to chronic pelvic pain syndrome.