Randomized Controlled Trial Comparing Pudendal Nerve Block Under Ultrasound and Fluoroscopic Guidance:

Fluoroscopy-Guided Transgluteal Pudendal Nerve Block for Pudendal Neuralgia: A Retrospective Case Series

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.

Interventional Pain Management in the Treatment of Chronic Pelvic Pain

PURPOSE OF REVIEW

Chronic pelvic pain syndrome (CPPS) is a common yet complex disease in the field of urology, gynecology, and pain management. This review article summarizes the anatomy and physiology of CPP with an in-depth discussion of established and emerging interventional treatment options.

RECENT FINDINGS

Though psychosocial variables play a significant role in the development and propagation of CPPS, interventional treatment strategies are available to ameliorate symptoms. Sympathetic and peripheral nerve blocks along with chemical and radiofrequency denervation are conventional, evidence-based treatments. Recent advances in spinal cord stimulation and dorsal root ganglion stimulation offer novel and effective therapeutic options to treat CPPS. A biopsychosocial model should be employed for effective management of CPPS with advances in neuromodulation offering newfound hope in alleviating symptoms and restoring function.

Dorsal Root Ganglion Stimulation Therapy for Refractory Idiopathic Pudendal Neuralgia

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.

Pain Specialist Management of Sexual Pain-II: Interventional

INTRODUCTION

Treatment of female sexual pain often requires the use of diverse modalities crossing multiple medical disciplines. Interventional procedures are important in the diagnosis and treatment of female sexual pain. Pain specialists and other medical specialties can provide these capabilities.

OBJECTIVES

To provide a current summary of the procedures used in the diagnosis and treatment of female sexual pain.

METHODS

The internet, PubMed, and the Cochrane Library were searched for relevant articles on female sexual pain within the clinical purview and scope of the practice of pain management.

RESULTS

A thorough review of the literature was conducted to include basic science studies, clinical trials, systematic reviews, consensus statements, and case reports. An effort was made to also include a sampling of information on real-world patient self-directed therapies. Descriptions of interventional procedures for the diagnosis and treatment of sexual pain were made and clinical studies reviewed. The evidence for the use of various interventional treatment strategies for sexual pain was assessed.

CONCLUSIONS

The process of care for female sexual pain employs an interdisciplinary biopsychosocial model that includes a role for interventional procedures commonly performed by pain management specialists. These specialists are a resource of knowledge, skills, and abilities that can be used to improve the care of women with chronic sexual pain.

Ultrasound-guided Musculoskeletal Interventional Procedures Around the Hip: A Practical Guide

Several studies have shown that ultrasound guidance may contribute to improved safety, effectiveness and accuracy of musculoskeletal interventional procedures performed around the hip if compared to those performed with a landmark-guided technique. Different approaches and injectates can be used for treating hip musculoskeletal disorders. These procedures may involve injections in the hip joint, periarticular bursae, tendons, and peripheral nerves. Intra-articular hip injections are mostly used as a conservative approach for treating patients affected by hip osteoarthritis. Ultrasound-guided injection of the iliopsoas bursa is performed in patients with bursitis and/or tendinopathy, to treat those with painful prosthesis due to iliopsoas impingement, or when the lidocaine test is indicated to identify the iliopsoas as a source of pain. Ultrasound-guided interventions are routinely used in patients with greater trochanteric pain syndrome having as target the gluteus medius/minimus tendons and/or the trochanteric bursae. Ultrasound-guided fenestration and platelet-rich plasma injection are applied in patients with hamstring tendinopathy with good clinical outcomes. Last but not least, ultrasound-guided perineural injections can be used for peripheral neuropathies or blocks of the sciatic, lateral femoral cutaneous, and pudendal nerves. In this paper, we discuss the evidence and technical tips for musculoskeletal interventional procedures performed around the hip, highlighting the added value of ultrasound as an imaging guidance modality.

Sonoanatomy of the ilioinguinal, iliohypogastric, genitofemoral, obturator, and pudendal nerves: a practical guide for US-guided injections

The ilioinguinal, iliohypogastric, genitofemoral, obturator, and pudendal nerves are the major sensory nerves that may be involved in chronic groin and genital pain with a significant impact on the quality of life of patients. The diagnosis remains clinical, and US-guided diagnostic injections using an anesthetic may aid in confirming the clinical suspicion. The anatomy of the peripheral nerves can be successfully studied using imaging. High-resolution ultrasound is increasingly used in the clinical setting for visualizing small peripheral nerves, and magnetic resonance imaging provides an anatomical overview of the relationship between small nerves and surrounding structures. In this pictorial assay, we review the anatomy and clinical relevance of the ilioinguinal, iliohypogastric, genitofemoral, obturator, and pudendal nerves. We summarize the various techniques for ultrasound identification, and present the ultrasound-guided infiltration techniques for injecting the ilioinguinal, iliohypogastric, genitofemoral, obturator, and pudendal nerves. Corresponding magnetic resonance images and clinical photos of the probe placement technique are provided for anatomical correlation. This paper is aimed to serve as a practical technical guide for physicians to familiarize themselves with the ultrasound anatomy of the major inguinal sensory nerves and to enable successful ultrasound identification and ultrasound-guided diagnostic or therapeutic infiltrations for pain management of the ilioinguinal, iliohypogastric, genitofemoral, obturator, and pudendal nerves.

The Efficacy of an Ultrasound-Guided Improved Puncture Path Technique of Nerve Block/Pulsed Radiofrequency for Pudendal Neuralgia: A Retrospective Study

Objectives: To investigate the efficacy and safety of an improved ultrasound-guided pulsed radiofrequency (PRF) and nerve block (NB) for patients with pudendal neuralgia (PN). Methods: This retrospective analysis included 88 adults with PN treated in the Pain Department of Southwest Hospital from November 2011 to June 2021, with treatment including NB (n = 40) and PRF (n = 48). The primary outcome variable was pain severity, measured by a standardized visual analog scale (VAS). VAS values were collected at 1, 3, 7, and 14 days and 1 and 3 months after patients were treated with NB or PRF. Results: Compared with patients treated with NB (n = 40) and those treated with PRF (n = 48), no significant difference in pain reduction was observed in the short term (p = 0.739 and 0.981, at 1 and 3 days, respectively); however, in the medium and long term (1 to 3 months), there were statistically significant improvements in the PRF group over the NB group (p < 0.001). Moreover, it was noted that the average pain severity of primary PN and PN due to sacral perineurial cyst was significantly reduced with PRF therapy in the medium and long term when compared to other secondary PNs, including surgery, trauma, and diabetes. Discussion: The ultrasound-guided, improved, and innovative PRF/NB puncture path technique allows for gentler stimulation and faster identification of the pudendal nerve. The PRF technique may provide better treatments for primary PN and sacral perineurial cyst causing secondary PN in the medium and long term.

Clinical indications for image-guided interventional procedures in the musculoskeletal system: a Delphi-based consensus paper from the European Society of Musculoskeletal Radiology (ESSR)-part VII, nerves of the lower limb

OBJECTIVES

To perform a Delphi-based consensus on published evidence on image-guided interventional procedures for peripheral nerves of the lower limb (excluding Morton's neuroma) and provide clinical indications.

METHODS

We report the results of a Delphi-based consensus of 53 experts from the European Society of Musculoskeletal Radiology who reviewed the published literature for evidence on image-guided interventional procedures offered around peripheral nerves in the lower limb (excluding Morton's neuroma) to derive their clinical indications. Experts drafted a list of statements and graded them according to the Oxford Centre for evidence-based medicine levels of evidence. Consensus was considered strong when > 95% of experts agreed with the statement or broad when > 80% but < 95% agreed. The results of the Delphi-based consensus were used to write the paper.

RESULTS

Nine statements on image-guided interventional procedures for peripheral nerves of the lower limb have been drafted. All of them received strong consensus. Image-guided pudendal nerve block is safe, effective, and well tolerated with few complications. US-guided perisciatic injection of anesthetic provides good symptom relief in patients with piriformis syndrome; however, the addition of corticosteroids to local anesthetics still has an unclear role. US-guided lateral femoral cutaneous nerve block can be used to provide effective post-operative regional analgesia.

CONCLUSION

Despite the promising results reported by published papers on image-guided interventional procedures for peripheral nerves of the lower limb, there is still a lack of evidence on the efficacy of most procedures.

KEY POINTS

• Image-guided pudendal nerve block is safe, effective, and well tolerated with few complications. • US-guided perisciatic injection of anesthetic provides good symptom relief in patients with piriformis syndrome; however, the addition of corticosteroids to local anesthetics still has an unclear role. • US-guided lateral femoral cutaneous nerve block can be used to provide effective post-operative regional analgesia. The volume of local anesthetic affects the size of the blocked sensory area.

Comparative study between ultrasound-guided pudendal nerve block and caudal epidural block anesthesia in children undergoing hypospadias surgery

Background

The aim of the study is to compare the effectiveness and safety of ultrasound-guided pudendal nerve block versus caudal epidural block as a part of multimodal analgesia in children undergoing hypospadias surgery.

In this prospective, single-blinded study, 50 patients were randomized into 2 groups (25 each group) either receiving ultrasound-guided pudendal nerve block group A or caudal epidural block group B. In the pudendal nerve block group, patients were injected with 0.3 mL/kg 0.25% bupivacaine and 1 ug/kg fentanyl. In the caudal epidural group, patients were injected with 1 mL/kg 0.25% bupivacaine and 1 ug/kg fentanyl. Consumption of paracetamol was assessed during the first 24 h postoperatively. The “objective pain scale” done by Hannalah and Broadman was used to assess postoperative pain.

Results

This prospective randomized controlled single-blind clinical study was performed on total (50) ASA status I or II patients, of age 3 to 6 years scheduled for hypospadias surgery.

For the primary outcome, there was no statistically significant difference found between the two studied groups regarding objective pain score at arrival to PACU with p value = 1.000 while there was a statistically significant increase in pain score in group B than group A at 6 h and 12 h with p value = 0.017 and 0.003, respectively. Also, no statistically significant difference found between the two groups after 18 h with p value = 0.238 may be due to receiving acetaminophen dose in group B. Finally there was a statistically significant increase found in objective pain score in group B at 24 h than group A with p value = 0.015. And there was a statistically significant increase in time to first analgesia in group A than group B with p value < 0.001 while there was a statistically significant increase in total dose of acetaminophen in group B than group A with p value < 0.001.

Conclusion

Both ultrasound-guided pudendal block and caudal epidural block are effective and safe methods for postoperative analgesia for children undergoing hypospadias surgery but ultrasound-guided pudendal block gives more postoperative pain control.

Development of an ultrasound-guided transgluteal injection of the pudendal nerve in cats: a cadaveric study

OBJECTIVE

To develop an ultrasound-guided interfascial plane technique for injection of the pudendal nerve near its sacral origin in cats.

STUDY DESIGN

Prospective, randomized, anatomical study.

ANIMALS

A group of 12 feline cadavers.

METHODS

Gross and ultrasound anatomy of the ischiorectal fossa, the pudendal nerve relationship with parasacral structures, and the interfascial plane were described. Computed tomography was employed to describe a cranial transgluteal approach to the pudendal nerve. Bilateral ultrasound-guided injections were performed in eight cadavers using low [(LV) 0.1 mL kg^-1] or high volume [(HV) 0.2 mL kg^-1] of ropivacaine-dye solution. Dissections were performed to determine successful staining of the pudendal nerve (>1 cm) and inadvertent staining of the sciatic nerve, and any rectal, urethral, or intravascular puncture. Pudendal nerve staining in groups LV and HV were compared using Fisher's exact and Wilcoxon rank-sum test as appropriate (p = 0.05).

RESULTS

The pudendal nerve and its rectal perineal and sensory branches coursed through the ischiorectal fossa, dorsomedial to the ischiatic spine. The pudendal nerve was not identified ultrasonographically, but the target plane was identified between the sacral transverse process, the ischiatic spine, the pelvic fascia and the rectum, and it was filled with dye solution. Both branches of the pudendal nerve were completely stained 75% and 87.5% in groups LV and HV, respectively (p = 1.00). The dorsal aspect of the sciatic nerve was partially stained in 37% of injections in group HV. Rectal or urethral puncture and intravascular injection were not observed.

CONCLUSIONS AND CLINICAL RELEVANCE

In cats, ultrasound-guided cranial transgluteal injection successfully stained the pudendal nerve in at least 75% of attempts, regardless of injectate volume. Group HV had a greater probability of sciatic nerve staining.

The Use of Radiofrequency in the Treatment of Pelvic Pain

Radiofrequency ablation (RFA) is a procedure in which radio waves are used to destroy abnormal or dysfunctional tissue. It has been an increasingly utilized treatment option for a variety of medical conditions, such as chronic pain, wherein sensory nerves are targeted and ablated, eliminating their ability to transmit pain signals to the brain. There is a lack of clarity regarding the indications, technique, and efficacy of RFA for chronic pelvic pain. This article reviews recent literature and discusses these topics, including adverse events for different pelvic ablation and pulsed radiofrequency treatment of chronic pelvic pain.

Ultrasound-guided injections in pelvic entrapment neuropathies

Pelvic entrapment neuropathies represent a group of chronic pain syndromes that significantly impede the quality of life. Peripheral nerve entrapment occurs at specific anatomic locations. There are several causes of pelvic entrapment neuropathies, such as intrinsic nerve abnormality or inflammation with scarring of surrounding tissues, and surgical interventions in the abdomen, pelvis and the lower limbs. Entrapment neuropathies in the pelvic region are not widely recognized, and still tend to be underdiagnosed due to numerous differential diagnoses with overlapping symptoms. However, it is important that entrapment neuropathies are correctly diagnosed, as they can be successfully treated. The lateral femoral cutaneous nerve, ischiadic nerve, genitofemoral nerve, pudendal nerve, ilioinguinal nerve and obturator nerve are the nerves most frequently causing entrapment neuropathies in the pelvic region. Understanding the anatomy as well as nerve motor and sensory functions is essential in recognizing and locating nerve entrapment. The cornerstone of the diagnostic work-up is careful physical examination. Different imaging modalities play an important role in the diagnostic process. Ultrasound is a key modality in the diagnostic work-up of pelvic entraptment neuropathies, and its use has become increasingly widespread in therapeutic procedures. In the article, the authors describe the background of pelvic entrapment neuropathies with special focus on ultrasound-guided injections.

Accuracy of Ultrasound-Guided Pudendal Nerve Block in the Ischial Spine and Alcock's Canal Levels: A Cadaveric Study

BACKGROUND

Blockade of the pudendal nerve (PN) using ultrasound (US) guidance has been described at the levels of the ischial spine and Alcock's canal. However, no study has been conducted to compare anatomical accuracy between different approaches in targeting the PN.

OBJECTIVE

To investigate the accuracy of US-guided injection of the PN at the ischial spine and Alcock's canal levels. This study also compared the accuracy of the infiltrations by three sonographers with different levels of experience.

SUBJECTS

Eight Thiel-embalmed cadavers (16 hemipelvises).

METHODS

Three physiatrists trained in musculoskeletal US imaging with 12 years, five years, and one year of experience performed the injections. Each injected a 0.1-mL bolus of colored dye in both hemipelvises of each cadaver at the ischial spine and Alcock's canal levels under US guidance. Each cadaver received three injections per hemipelvis. The accuracy of the injection was determined following hemipelvis dissection by an anatomist.

RESULTS

The injections were accurate 33 times out of the total 42 attempts, resulting in 78% accuracy. Sixteen out of 21 injections at the ischial spine level were on target (76% accuracy), while the approach at Alcock's canal level yielded 17 successful injections (81% accuracy). The difference between the approaches was not statistically significant. There was also no significant difference in accuracy between the operators.

CONCLUSIONS

US-guided injection of the PN can be performed accurately at both the ischial spine and Alcock's canal levels. The difference between the approaches was not statistically significant.

Ultrasound-Guided Pudendal Nerve Block Combined with Propofol Deep Sedation versus Spinal Anesthesia for Hemorrhoidectomy: A Prospective Randomized Study

Background and Objectives. Several anesthesia techniques were applied to hemorrhoidectomy, but postoperative pain and urinary retention were still two unsolved problems. The aim of this prospective randomized study was to evaluate the effect of ultrasound-guided pudendal nerve block (PNB) combined with deep sedation compared to spinal anesthesia for hemorrhoidectomy. Methods. One hundred and twenty patients undergoing Milligan-Morgan hemorrhoidectomy were randomized to receive PNB combined with deep sedation using propofol (Group PNB, n = 60) or spinal anesthesia (Group SA, n = 60). Pain intensity was assessed using the visual analogue scale (0: no pain to 10: worst possible pain). The primary outcome was pain scores recorded at rest at 3, 6, 12, 24, 36, and 48 h and on walking at 12, 24, 36, and 48 h postoperatively. Secondary outcomes were analgesic consumption, side effects, and patient satisfaction after surgery. Results. Ultrasound-guided bilateral PNB combined with deep sedation using propofol could successfully be applied to Milligan-Morgan hemorrhoidectomy. Postoperative pain intensity was significantly lower in Group PNB compared to Group SA at rest at 3, 6, 12, 24, 36, and 48 h (p < 0.001) and during mobilization at 12, 24, 36, and 48 h (p < 0.001) postoperatively. Sufentanil consumption in Group PNB was significantly lower than that in Group SA, during 0-24 h (p < 0.001) and during 24-48 h (p < 0.001) postoperatively. Urinary retention was significantly lower in Group PNB compared to Group SA (6.9% vs 20%, p=0.034). The patients in Group PNB had higher satisfaction compared to Group SA (p < 0.001). Conclusions. Ultrasound-guided PNB combined with propofol sedation is an effective anesthesia technique for Milligan-Morgan hemorrhoidectomy.

Pre-emptive digitally guided pudendal block after posterior vaginal repair

Introduction and hypothesis

The aim of this study was to establish if digitally guided pre-emptive pudendal block (PDB) reduces postoperative pain and facilitates recovery after posterior vaginal repair under local anesthesia and sedation.

Methods

We carried out a prospective, randomized, double-blind trial in an outpatient surgery facility. Forty-one women between 18 and 70 years of age, scheduled for primary posterior vaginal reconstructive outpatient surgery, completed the study. The surgery was performed using sedation and local anesthesia with bupivacaine/adrenaline. At the end of surgery, 20 ml of either ropivacaine 7.5 mg/ml or sodium chloride (placebo) was administered as a digitally guided PDB. The primary aim was to establish if PDB with ropivacaine compared with placebo reduced the maximal pain as reported by visual analog scale (VAS) during the first 24 h after surgery. Secondary aims were to compare the duration and experience of the hospital stay, nausea, need for additional opioids, and adverse events.

Results

PDB with ropivacaine after local infiltration with bupivacaine/adrenaline after outpatient posterior repair did not significantly reduce maximal postoperative pain, need for hospital admittance, nausea, or opioid use. Mild transient sensory loss occurred after ropivacaine in two women. Two women the placebo group were unable to void owing to severe postoperative pain, which was resolved by a rescue PDB.

Conclusions

When bupivacaine/adrenaline is used for anesthesia in posterior vaginal repair, PDB with ropivacaine gives no benefit regarding postoperative pain, recovery or length of hospital stay. Rescue PDB can be useful for postoperative pain relief.

The Role of Pudendal Nerve Block in Colorectal Surgery: A Systematic Review

BACKGROUND

Colorectal surgery is associated with significant pain often requiring opioid and non-opioid analgesics. Pudendal nerve blocks (PNBs) can be administered with the aim to reduce pain and improve patient satisfaction. However, there are no current accepted guidelines for the use of PNB in colorectal surgery.

METHOD

We evaluated the available literature on the role of PNB in colorectal surgery to determine which technique and anesthetic agent may provide optimal pain relief and safety. Studies from January 1970 to December 2019 assessing PNB in colorectal surgery were retrieved from MEDLINE and EMBASE databases. Indication for PNB, technique, anesthetic agent, postoperative pain outcomes, patient satisfaction and complications were extracted.

RESULTS

We initially identified 339 studies of which 17 (nine randomized controlled trials, three cohort studies, one case-control study and four reviews) specifically met the inclusion criteria. The most common indication found for PNB is hemorrhoidectomy using either bupivacaine or lidocaine. The anatomical landmark and neurostimulation are the most favorable techniques being applied. The majority of studies reported better pain scores, less analgesia requirement and higher patient satisfaction when performing a bilateral PNB, with no major complications.

CONCLUSIONS

The current evidence, though limited, supports the use of bilateral PNBs in colorectal surgical procedures in particular hemorrhoidectomies. PNBs can be safe and effective in improving patient outcomes particularly when using bupivacaine or lidocaine with either the anatomical landmark or neurostimulation technique.

Comparison of Ultrasound-Guided Transgluteal and Finger-Guided Transvaginal Pudendal Nerve Block Techniques: Which One is More Effective?

Purpose

Pudendal neuralgia (PN) is a painful and disabling condition, which reduces the quality of life as well. Pudendal nerve infiltrations are essential for the diagnosis and the management of PN. The purpose of this study was to compare the effectiveness of finger-guided transvaginal pudendal nerve infiltration (TV-PNI) technique and the ultrasound-guided transgluteal pudendal nerve infiltration (TG-PNI) technique.

Methods

Forty patients who underwent PNI for the diagnosis of PN were evaluated. Thirty-five of these 40 patients, who were diagnosed as PN, underwent a total of 70 further unilateral PNI. All the patients underwent PNI for twice after the first diagnostic PNI, 1 week apart.

Results

In the ultrasound (US)-guided TG-PNI group, the success rate was 68.8% (11 of 16) in both “pain in the sitting position” and “pain in the region from the anus to the clitoris.” The success rate of blocks in the US-guided TG-PNI group was 75% (12 of 16) in terms of pain during/after intercourse. In the finger-guided TV-PNI group, the success rate was 84.2% in both “pain in the sitting position” and “pain in the region from the anus to the clitoris.” The success rate of blocks in the fingerguided TV-PNI group was 89.5% (17 of 19) in terms of pain during/after intercourse. There was no statistically significant difference in the success rate of the 3 assessed conditions between the 2 groups (P>0.05).

Conclusions

The TV-PNI may be an alternative to US-guidance technique as a safe, simple, effective approach in pudendal nerve blocks.

Initial experience of CT-guided pulsed radiofrequency ablation of the pudendal nerve for chronic recalcitrant pelvic pain

AIM

To evaluate initial experience with computed tomography (CT)-guided pulsed radiofrequency ablation (pRFA) of the pudendal nerve in cases of recalcitrant neuropathic pelvic pain. Endpoints include technical feasibility, safety, and efficacy of therapy.

MATERIALS AND METHODS

Ten patients who underwent pRFA ablation for neuropathic pudendal nerve pain during the trial period were followed for response to treatment for 6 months. Each patient was treated with pRFA under CT-guidance with concurrent perineural injection of anaesthetic and/or corticosteroid. Pain scores were then measured using a numeric rating scale at fixed intervals up to 6 months.

RESULTS

All procedures were considered technically successful with no immediate complications. pRFA demonstrated improved duration of pain improvement compared to the most recent perineural injection (p=0.0195), but not compared to the initial injection (p=0.64). Reported pain scores were lower with pRFA than with both the first and most recent injection but this did not reach statistical significance (p=0.1094 and p=0.7539, respectively).

CONCLUSION

Overall, pRFA of the pudendal nerve using CT-guidance can be a safe and effective therapy. This technique provides direct visualisation of the nerve to maximise safety and efficacy while offering a novel form of therapy for patients with chronic, recalcitrant pelvic pain.

Neuropatía del pudendo como causa de dolor pélvico

El síndrome de atrapamiento del nervio pudendo es una de múltiples causas de dolor pélvico crónico. Hemos realizado una revisión de la literatura sobre su presentación clínica, diagnóstico y tratamiento, con el propósito de conocer los detalles más relevantes de una enfermedad que cada vez está siendo más diagnosticada, con el fin de realizar un abordaje precoz desde un punto de vista integral.

Ultrasound-guided pudendal nerve block in children: A new technique of ultrasound-guided transperineal approach

BACKGROUND

Transperineal pudendal nerve block guided by nerve stimulator is used in pediatric anesthesia as an alternative to caudal analgesia in perineal surgery. The risk of rectal puncture or intravascular injection is inherent to this blinded technique. We described a new technique of transperineal pudendal nerve block, with ultrasound guidance, to improve safety of the technique.

AIMS

The first goal of this study was to describe this new technique and to test its feasibility. The second objective was to evaluate intra operative effectiveness and postoperative pain control.

METHODS

After parental and children consent, this prospective descriptive study included children aged 1-15 years, ASA status I-III, scheduled for general anesthesia associated with bilateral pudendal nerve block for an elective perineal surgery. After standardized general anesthesia, the anesthesiologist performed pudendal nerve block under ultrasound guidance with "out of plane" approach and evaluated the visualization of anatomical structures (ischial tuberosity, rectum, and pudendal artery), of the needle and of the local anesthetic spread. Pudendal nerve block failure was defined as an increase in mean arterial blood pressure or heart rate more than 20% compared to baseline values after surgical incision. In the postoperative period, the need for rescue analgesia was noted.

RESULTS

During the study period, 120 blocks were performed in 60 patients, including 59 boys. Quality of the ultrasonographic image was good in 81% of blocks, with easy visualization of ischium and rectum in more than 95% of cases. Localization of the tip of the needle was possible for all pudendal nerve blocks, directly or indirectly. The spread of local anesthetic was seen in 79% of cases. The block was effective in 88% of cases.

CONCLUSION

The new technique of ultrasound-guided pudendal nerve block, described in this study, seems to be easy to perform with a good success rate, and probably improves safety of the puncture and of the injection by real-time visualization of anatomical structures and local anesthetic spread.

Ultrasound-guided pulsed radiofrequency treatment of the pudendal nerve in chronic pelvic pain

Chronic pelvic pain is a condition that can be caused by pudendal neuralgia, interstitial cystitis, piriformis syndrome and neuropathy of the ilioinguinal, iliohypogastric and genitofemoral nerves. Based on three case reports this article discusses the clinical effectiveness of pulsed high-frequency radiofrequency (PRF) treatment applied to the pudendal nerve under ultrasound guidance in medicinally treated patients with chronic pelvic pain.

Management of pudendal neuralgia using ultrasound-guided pulsed radiofrequency: a report of two cases and discussion of pudendal nerve block techniques

Pudendal neuralgia is characterized by chronic pain or discomfort in the area innervated by the pudendal nerve, with no obvious cause. A successful pudendal nerve block is crucial for the diagnosis of pudendal neuralgia. Blind or fluoroscopy-guided pudendal nerve blocks have been conventionally used for diagnosis and treatment; however, ultrasound-guided pudendal nerve blocks were also reported recently. With regard to the achievement of long-term effects, although pulsed radiofrequency performed under fluoroscopic guidance has been reported, that performed under ultrasound guidance is not well reported. This report describes two cases of pudendal neuralgia that were successfully managed using ultrasound-guided pulsed radiofrequency and presents a literature review of pudendal nerve block techniques. However, in the management of chronic neuropathic pain, physicians should keep in mind that the placebo effect related to invasive approaches must not be neglected.

Ultrasound-guided interventional procedures for chronic pain management

Ultrasonography has multiple advantages over traditional radiologic imaging modalities when used for interventional procedures. It allows improved visualization of the anatomy while avoiding ionizing radiation and risks associated with contrast use. It has proved superiority at accuracy of delivery and procedural effectiveness over blind procedures when used in association with interventional pain procedures. Although limited in its ability to see through bony structures, ultrasound has utility in visualizing soft tissues and vascular structures in anatomic regions of interest resulting in increased use for posterior neuraxial, periaxial, peripheral nerve and joint-related structures. Current evidence for use in these settings is presented here. In some cases, optimal utility may be improved by combining ultrasonography with other imaging modalities.

New perineal injection technique for pudendal nerve infiltration in diagnostic and therapeutic procedures

PURPOSE

Pudendal nerve injection is used as a diagnostic procedure in the vulvar region and for therapeutic purposes, such as in vulvodynia. Here, we provide a new, easy-to-perform perineal injection technique.

PATIENTS AND METHODS

We analyzed 105 perineal injections into the pudendal nerve with a local anesthetic (LA), procaine in 20 patients. A 0.4 × 40 mm needle was handled using a stop-and-go technique while monitoring the patient's discomfort. The needle was placed 1-2 cm laterally to the dorsal introitus. After aspiration, a small amount of LA was applied. After subcutaneous anesthesia, the needle was further advanced step-by-step. Thus, 5 ml could be applied with little discomfort to the patient. Anesthesia in the pudendal target region was the primary endpoint of our analysis.

RESULTS

In 93 of 105 injections (88.6 %), complete perineal anesthesia was achieved with a single injection. 12 injections were repeated. These injections were excluded from the analysis. Severity of injection pain, on visual analog scale (VAS) from 0 to 100, was 26.8 (95 % CI 7.2-46.4). Age (β = 0.33, p < 0.01) and the number of previous injections (β = 0.35, p < 0.01) inversely correlated with injection pain. Injection pain and anesthesia were not affected by BMI, the number and the side of previous injections, or order of injection. A reversible vasovagal reaction was common, but no serious adverse effects occurred.

CONCLUSION

Perineal pudendal injection is an effective and safe technique for anesthesia in diagnostic (vulva biopsy) and therapeutic indications (pudendal neuralgia), and regional anesthesia in perinatal settings.

Relief of urinary urgency, hesitancy, and male pelvic pain with pulse radiofrequency ablation of the pudendal nerve: a case presentation

Background and Aims. This report demonstrates the utility of a pudendal nerve block by pulsed radiofrequency ablation (RFA) for the treatment of male pelvic pain and urinary urgency and hesitancy. Methods. The patient is an 86-year-old gentleman with a 30-year history of urinary hesitancy and urgency. The patient also had pain in the area of the perineum but considered it a secondary issue. The patient was seen by a number of specialists, tried various medications, and underwent a variety of procedures to no avail. Therefore, the patient underwent a pulsed RFA of the pudendal nerve. Results. The patient underwent a pulsed RFA of the pudendal nerve; the patient reported marked improvement in his pelvic pain as well as a drastic reduction in his urinary urgency and hesitancy. Conclusion. Urinary urgency and hesitancy and male pelvic pain are some of the most common symptoms affecting men. Pudendal nerve block by pulsed RFA is an effective treatment of pelvic pain. It may also hold some therapeutic value in the treatment of urinary urgency and hesitancy as our case demonstrated. Further studies are needed to help clarify both the anatomy of the pelvis as well as if pudendal blocks are effective in treating more than pelvic pain.