Pudendal Neuralgia: Fact or Fiction?

Management of pudendal neuralgia with electrical stimulation. A systematic review

INTRODUCTION AND OBJECTIVE

Pudendal neuralgia is a severely intense, painful, neuropathic condition, involving the dermatome of the pudendal nerve (S2, S3, S4). The diagnosis is complex and usually takes many years to be made. Techniques that use electrical current have been shown to decrease pain and improve quality of life in patients with this condition. The aim of this review was to analyze the existing literature on the effects of electrical current in the treatment of patients with pudendal neuralgia.

MATERIAL AND METHODS

A literature search was carried out in PubMed, Cinahl, Medline, Cochrane Library, ENFISPO, PEDro, Scopus and Web of Science databases, using the search terms "Electric Stimulation Therapy", "pudendal neuralgia" and "pudendal nerve entrapment".

RESULTS

The most frequently repeated intervention is pulsed radiofrequency. Other techniques used are transcutaneous electrical nerve stimulation, pulsed electromagnetic field therapy and neuromodulation. All studies show significant improvement in pain, analgesic intake, depression-anxiety or quality of life.

CONCLUSIONS

The application of electrical current seems to be effective in the management of pudendal neuralgia. The scientific evidence is scarce, of poor methodological quality, and its use is based on the efficacy demonstrated in other indications of chronic pain.

Sciatic foramen anatomy and common pathologies: a pictorial review

This article reviews the relevant anatomy, imaging features on computed tomography, magnetic resonance imaging, and management of common processes involving the sciatic foramen. The anatomy of the sciatic foramen is complex and provides an important conduit between the pelvis, gluteus, and lower extremity. This paper reviewed the anatomy, common pathologies, and imaging features of this region including trauma, infection, nerve entrapment, tumor spread, hernia, and vascular anomaly.

Interventional treatment options for women with pelvic pain

Purpose of review

I.To provide an overview of current interventional treatment options for women with chronic pelvic pain (CPP).

Recent findings

II.Accessibility of CT imaging, ultrasound, and fluoroscopy have assisted the development of novel interventional techniques. Similarly, neuromodulation techniques have improved with the development of novel stimulation patterns and device implants.

Summary

III.Numerous small-scale studies report high success rates with injection intervention therapies in CPP but there are limited well designed large-scale studies that demonstrate superiority of treatment. Female pelvic pain is difficult to diagnose due to the multifactorial etiology and the variable presentation causing delay in accurate diagnosis and lack of response to conventional medical and initial interventional therapies. Despite the shortfalls of current studies, collectively our understanding of chronic pain conditions and helpful injection interventions are improving. Undoubtedly the breadth of current research will provide a rich foundation for future large-scale well-designed studies involving multiple disciplines with more uniform methods and criteria to produce reliable and reproducible results.

Diagnostic and interventional magnetic resonance neurography diagnosis of brachytherapy seed-mediated pudendal nerve injury: a case report

Injury to the pudendal nerve in men presents with pain, paresthesia, or numbness of the perineum, and/or scrotum, and/or penis. There is evidence implicating the brachytherapy seeds used to treat prostate cancer as source of pudendal nerve injury. Compared to surgical prostatectomy, brachytherapy has the advantage of being less invasive, but seeds may not only lead to well-established complications such as urinary, bowel, and erectile dysfunction, but also injury to the sensory branches of the pudendal nerve. We report and document a case of pudendal nerve injury secondary to brachytherapy seeds diagnosed with magnetic resonance (MR) neurography, nerve blocks, and histopathological examination; and successful treatment via sensory branch neurectomy.

Estimate of the proportion of uncertain diagnoses of pudendal neuralgia in women with chronic pelvic-perineal pain: A systematic review with a descriptive data synthesis

BACKGROUND

There is a gap between pudendal neuralgia (PN) due to pudendal entrapment syndrome and PN without pudendal entrapment syndrome. The latter could have atypical symptoms.

AIM

Defining a rate of atypical PN from a clinical series of female patients with chronic pelvic-perineal pain.

METHODS

The atypical PN was defined as a pain not meeting clinical criteria for pudendal entrapment syndrome. The effect size was the rate of atypical PN. Such a rate was expected to be found among patients screened for enrollment in clinical series on pudendal neuropathic pain. A systematic search was performed looking for clinical series on PN. Studies must report information on female patients, pelvic-perineal pain, at least a clinical criterion for diagnosing the pudendal neurogenic origin of pain, the proportion of patients with pain not meeting the clinical criterion/a for diagnosing the pudendal entrapment pain.

RESULTS

From 2637 references, nine studies were included for qualitative analysis. Three of them were not suitable for data synthesis: one assessed the rate of PN after hip arthroscopy; second enrolled miscellaneous patients, a third investigated patients with gynecological diseases. Six studies involved patients with suspicion of pudendal entrapment symptoms (205 patients observed), allowing data synthesis. One of these series was judged as being of good quality. The overall rate of atypical PN is 0.013 (95% confidence interval, 0.008-0.021), I² 0%. Further analysis suggests the risk of bias for all studies.

CONCLUSIONS

Atypical PN in females is low when clinical criteria for pudendal entrapment syndrome are applied.

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.

Pudendal nerve 3-dimensional illustration gives insight into surgical approaches

The pudendal nerve is located topographically in areas in which plastic surgeon reconstruct the penis, the vagina, the perineum, and the rectum. This nerve is at risk for either compression or direct injury with neuroma formation from obstetrical, urogynecologic, and rectal surgery as well as pelvic fracture and blunt trauma. The purpose of this study was to create a 3-dimensional representation based on magnetic resonance imaging of the pelvis supplemented with new anatomic dissections in men and women to delineate the location of the pudendal nerve and its branches, providing educational information both for surgical intervention and patient education. The results of this study demonstrated that most often there are at least 2, not 1, "pudendal nerves trunks" as they leave the pelvis to transverse the sacrotuberous ligament, and that there are most often 2, not 1, exit(s) from Alcock canal, one for the dorsal branch and one for the perineal branch of the pudendal nerve.

Lower urinary tract dysfunction in patients with peripheral nervous system lesions

The prevalence of lower urinary tract (LUT) dysfunction in peripheral nervous system (PNS) disorders is larger than in comparable control populations. This is particularly true for polyneuropathies with autonomic nervous system involvement, and for localized lesions with LUT innervation. LUT symptoms may be the guide to the diagnosis of processes localized in the lumbosacral spinal canal (as in cauda equina syndrome), and in the pelvis. Typical LUT dysfunctions (LUTD) caused by PNS involvement include bladder and sphincter hypoactivity with poor emptying, and incontinence. Paradoxically, bladder overactivity may also occur in pure PNS lesions. The acute cauda equina syndrome is an emergency requiring magnetic resonance imaging and surgery; in chronic neurogenic LUTD due to PNS involvement, the diagnosis of the lesion may be clarified by clinical neurophysiologic testing. Other important causes of neurogenic LUT dysfunction are perineoabdominal and pelvic surgeries. Surgeons are devising nerve-sparing techniques to prevent such major and often persistent complications in patients who are otherwise cured of the underlying disease. LUTD significantly affects the quality of life in patients and may lead to recurring urinary infections and upper urinary tract involvement. Thorough assessment of LUT function by urodynamics may be necessary in patients who are not improved by simple conservative measures.

Sexual dysfunction in patients with peripheral nervous system lesions

Peripheral nervous system (PNS) disorders may cause sexual dysfunction (SD) in patients of both genders. These disorders include mainly polyneuropathies (particularly those affecting the autonomic nervous system (ANS)) and localized lesions affecting the innervation of genital organs. Impaired neural control may produce a malfunction of the genital response consisting of loss of genital sensitivity, erectile dysfunction, loss of vaginal lubrication, ejaculation disorder, and orgasmic disorder. In addition, there is often a loss of desire which actually has a complex pathogenesis, which goes beyond the mere loss of relevant nerve function. In patients who have no manifest health problems - particularly men with erectile dysfunction - one should always consider the possibility of an underlying polyneuropathy; in patients with SD after suspected denervation lesions of the innervation of genital organs within the lumbosacral spinal canal and in the pelvis, clinical neurophysiologic testing may clarify the PNS involvement. SD can alter self-esteem and lower patients' quality of life; opening up a discussion on sexual issues should be a part of the management of patients with PNS disorders. They may greatly benefit from counseling, education on coping strategies, and specific treatments.

Magnetic resonance neurography-guided nerve blocks for the diagnosis and treatment of chronic pelvic pain syndrome

Magnetic resonance (MR) neurography - guided nerve blocks and injections describe a techniques for selective percutaneous drug delivery, in which limited MR neurography and interventional MR imaging are used jointly to map and target specific pelvic nerves or muscles, navigate needles to the target, visualize the injected drug and detect spread to confounding structures. The procedures described, specifically include nerve blocks of the obturator nerve, lateral femoral cutaneous nerve, pudendal nerve, posterior femoral cutaneous nerve, sciatic nerve, ganglion impar, sacral spinal nerve, and injection into the piriformis muscle.

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.

6-day intensive treatment protocol for refractory chronic prostatitis/chronic pelvic pain syndrome using myofascial release and paradoxical relaxation training

PURPOSE

Chronic prostatitis/chronic pelvic pain syndrome continues to elude conventional therapy. Evidence supports the concept that phenotypes of pelvic muscular tenderness and psychosocial distress respond to myofascial trigger point release and specific relaxation training. This case series reports long-term outcomes of a 6-day intensive combination of such therapies in refractory cases.

MATERIALS AND METHODS

A total of 200 men with pain for a median of 4.8 years referred themselves to Stanford University Urology for participation in an established protocol. Daily 3 to 5-hour sessions including intrapelvic/extrapelvic physiotherapy, self-treatment training and paradoxical relaxation training provided a solid introduction to facilitate self-management. Subjects answered baseline and followup questionnaires at variable intervals after initiation of therapy including the National Institutes of Health Chronic Prostatitis Symptom Index, global response assessment and a psychological query.

RESULTS

We followed 116 men for a median of 6 months. Baseline total symptom index was 26 out of a maximum 43 points. Scores decreased by 30% (p <0.001) at followup with 60% of subjects demonstrating a 6-point or greater decrease (range 6 to 30). Domains of pain, urinary dysfunction and quality of life showed significant improvement (p <0.001). Global response assessment revealed that 82% of subjects reported improvement (59% marked to moderate, 23% slight).

CONCLUSIONS

Men with chronic pelvic pain refractory to traditional treatment benefit from intensive myofascial trigger point therapy and concomitant paradoxical relaxation training. Education in techniques for self-administered trigger point release and continued pelvic muscle relaxation help patients reduce pain and dysfunction. Refinement of clinical phenotyping and selection of patients with pelvic muscle tenderness should enhance the success rate with this treatment modality.

Optimal management of chronic cyclical pelvic pain: an evidence-based and pragmatic approach

This article reviews the literature on management of chronic cyclical pelvic pain (CCPP). Electronic resources including Medline, PubMed, CINAHL, The Cochrane Library, Current Contents, and EMBASE were searched using MeSH terms including all subheadings and keywords: "cyclical pelvic pain", "chronic pain", "dysmenorrheal", "nonmenstrual pelvic pain", and "endometriosis". There is a dearth of high-quality evidence for this common problem. Chronic pelvic pain affects 4%-25% of women of reproductive age. Dysmenorrhea of varying degree affects 60% of women. Endometriosis is the commonest pathologic cause of CCPP. Other gynecological causes are adenomyosis, uterine fibroids, and pelvic floor myalgia, although other systems disease such as irritable bowel syndrome or interstitial cystitis may be responsible. Management options range from simple to invasive, where simple medical treatment such as the combined oral contraceptive pill may be used as a first-line treatment prior to invasive management. This review outlines an approach to patients with CCPP through history, physical examination, and investigation to identify the cause(s) of the pain and its optimal management.

Musculoskeletal pain and sexual function in women

INTRODUCTION

Sexual pain disorders refer to conditions of genital pain that interfere with intercourse. They often have a musculoskeletal component related to the pelvic floor and are included in the DSM-IV as sexual dysfunctions. Musculoskeletal pain (MP) that is not essentially genitally based often interferes with sex as well yet is not considered a distinct sexual dysfunction. MP is generally addressed by physiatrists, orthopedists, and rheumatologists who are not traditionally trained in sexual medicine, and therefore, the sexual concerns of women with MP often go unaddressed.

AIM

The purposes of this review article were to describe how MP is perceived in the literature as affecting sexual function, illustrate how specific MP conditions prevalent in women may affect sexual function, and offer recommendations for clinical practice.

METHODS

PubMed and Medline searches were performed using the keywords "musculoskeletal pain and sex,""lower back pain and sex,""arthritis and sex," and "fibromyalgia and sex". Main Outcome Measure. Review of the peer-reviewed literature.

RESULTS

Most studies cite fatigue, medication, and relationship adjustment as affecting sexuality much as chronic illness does. While musculoskeletal contributors to genital sexual response and pain are considered relevant to sexual function, little is understood about how MP syndromes specifically affect sexual activity.

CONCLUSION

Lack of mobility and MP can restrict intercourse and limit sexual activity, and gender differences are noted in response to pain. Sexual and relationship counseling should be offered as a component of rehabilitative treatment. Physical therapists are uniquely qualified to provide treatment to address functional activities of daily living, including sexual intercourse, and offer advice for modifications in positioning.