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Vogel JJ. Pain Specialist Management of Sexual Pain-II: Interventional. Sex Med Rev 2023; 11:81-88. [PMID: 36763948 DOI: 10.1093/sxmrev/qeac011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 12/06/2022] [Accepted: 12/09/2022] [Indexed: 01/20/2023]
Abstract
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.
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Affiliation(s)
- John J Vogel
- Innovative Pain Care, Marietta, GA 30062, United States
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Cain A, Carter K, Salazar C, Young A. When and How to Utilize Pudendal Nerve Blocks for Treatment of Pudendal Neuralgia. Clin Obstet Gynecol 2022; 65:686-698. [PMID: 35703212 DOI: 10.1097/grf.0000000000000715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Chronic pelvic pain is a common cause of pain in reproductive age women with debilitating consequences for affected women's health and quality of life. Treatment providers must be well versed in all treatment options for these patients, understanding the overlap in the management and treatment of chronic pelvic pain caused by pudendal neuralgia, myofascial pelvic pain, and vulvodynia. Pudendal blocks are a simple and quick procedure that can be performed in the office and often helps improve all the above conditions when used along with other treatment options. We review the anatomy and methodology on when and how to perform pudendal blocks in the office to better inform the general gynecologist on how to implement offering this treatment in the outpatient clinical setting.
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Affiliation(s)
- Abigail Cain
- The Dell Medical School at The University of Texas at Austin, Austin, Texas
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Basol G, Kale A, Gurbuz H, Gundogdu EC, Baydilli KN, Usta T. Transvaginal pudendal nerve blocks in patients with pudendal neuralgia: 2-year follow-up results. Arch Gynecol Obstet 2022; 306:1107-1116. [PMID: 35633372 DOI: 10.1007/s00404-022-06621-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Accepted: 05/07/2022] [Indexed: 11/02/2022]
Abstract
PURPOSE Pudendal neuralgia (PN) is an extremely painful neuropathy of the pudendal nerve resulting in a negative impact on a patient's quality of life. The aim of this study is to evaluate the 2-year outcomes of repetitive doses of the transvaginal pudendal nerve injections (PNI), and to compare the success of the PNI concerning anatomical levels (endopelvic and extrapelvic portion) of the pudendal nerve pathology. METHODS This retrospective longitudinal cohort study consists of patients with PN diagnosed with the first four essential Nantes criteria. Diagnostic PNI was performed on 67 patients to fulfill the fifth criteria of Nantes. A total of 56 patients who responded to the initial diagnostic PNI underwent therapeutic repeated transvaginal PNIs twice for 3 weeks apart. Mean pain intensity scores were measured using a visual analog scale at the 1st, 3rd, 6th, 12th, and 24th months after the therapeutic blocks were completed. Effectiveness of the PNIs' was defined as ≥ 50% improvement of the initial pain, and relative improvement was defined as 30-50% improvement of the initial pain. Treatment failure was defined as the reduction of the initial pain by less than 30% or the return of the pain to its worst condition. RESULTS The efficacy of the PNIs significantly declined over time. Pudendal nerve blocks provided a significant decrease in pain scores; however, this decrease lost its strength significantly in the 24th month. The intervention was more effective in entrapments of the pudendal nerve between sacrospinous and sacrotuberous ligaments or below (Level-2) when compared to the injuries in the endopelvic part (Level-1). More than 50% pain reduction continued in five patients with pathology at Level-1 and 24 patients with pathology at Level-2. CONCLUSION Repeated PNIs could provide a significant decrease in pain scores for both short- and long-term periods. However, the efficacy of the PNIs declined over 2 years. The success of PNIs may be affected by the anatomical level of the nerve injury; therefore, interligamentous pudendal nerve entrapment cases have more benefits than the cases of pudendal nerve entrapment in the endopelvic part. However, it is recommended to perform therapeutic nerve blocks even in patients with suspected endopelvic pudendal nerve pathology before the referral to surgery.
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Affiliation(s)
- Gulfem Basol
- Department of Obstetrics and Gynecology, University of Health Science Kartal Dr. Lutfi Kirdar City Hospital, Istanbul, Turkey
| | - Ahmet Kale
- Department of Obstetrics and Gynecology, University of Health Science Kartal Dr. Lutfi Kirdar City Hospital, Istanbul, Turkey
| | - Hande Gurbuz
- Department of Anesthesiology and Reanimation, Bursa Yuksek Ihtisas Training and Research Hospital Mimar Sinan Mh, Emniyet Cd., 16310, Bursa, Turkey. .,Department of Anatomy, Kocaeli University School of Medicine, Kocaeli, Turkey.
| | - Elif Cansu Gundogdu
- Department of Obstetrics and Gynecology, University of Health Science Kartal Dr. Lutfi Kirdar City Hospital, Istanbul, Turkey
| | - Kursad Nuri Baydilli
- Management and Organization Program, University of Health Sciences, Istanbul, Turkey
| | - Taner Usta
- Department of Obstetrics and Gynecology, Acibadem University, Altunizade Hospital, Istanbul, Turkey
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Murer S, Polidori G, Beaumont F, Bogard F, Polidori É, Kinne M. Advances in the therapeutic approach of pudendal neuralgia: a systematic review. J Osteopath Med 2021; 122:1-13. [PMID: 34800013 DOI: 10.1515/jom-2021-0119] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 08/09/2021] [Indexed: 12/29/2022]
Abstract
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.
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Affiliation(s)
- Sébastien Murer
- MATIM, UFR Sciences Exactes et Naturelles, Université de Reims Champagne-Ardenne, Campus Moulin de la Housse, Reims, France
| | | | | | - Fabien Bogard
- MATIM, Université de Reims Champagne-Ardenne, Reims, France
| | - Élisa Polidori
- ESO Paris SUPOSTEO, Higher School of Osteopathy, Paris, France
| | - Marion Kinne
- ESO Paris SUPOSTEO, Higher School of Osteopathy, Paris, France
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Wei YC, Jin HY, Zhang CX, Zhang XY, Ye XR, Wang C. Clinical diagnosis and treatment of functional anorectal pain. Shijie Huaren Xiaohua Zazhi 2021; 29:1-6. [DOI: 10.11569/wcjd.v29.i1.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Functional anorectal pain (FARP) is a kind of nonorganic, idiopathic pain that occurs in the anus and/or rectum. The pathogenesis of FARP is very complex, and there is no unified conclusion in the academic world. This paper reviews the clinical diagnosis and treatment of FARP to provide a reference for clinicians.
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Affiliation(s)
- Yuan-Cheng Wei
- Anorectal Disease Diagnosis and Treatment Center, Second Affiliated Hospital of Nanjing University of Traditional Chinese Medicine, Nanjing 210017, Jiangsu Province, China
| | - Hei-Ying Jin
- Anorectal Disease Diagnosis and Treatment Center, Second Affiliated Hospital of Nanjing University of Traditional Chinese Medicine, Nanjing 210017, Jiangsu Province, China
| | - Chun-Xia Zhang
- Anorectal Disease Diagnosis and Treatment Center, Second Affiliated Hospital of Nanjing University of Traditional Chinese Medicine, Nanjing 210017, Jiangsu Province, China
| | - Xin-Yi Zhang
- Anorectal Disease Diagnosis and Treatment Center, Second Affiliated Hospital of Nanjing University of Traditional Chinese Medicine, Nanjing 210017, Jiangsu Province, China
| | - Xiao-Rui Ye
- Anorectal Disease Diagnosis and Treatment Center, Second Affiliated Hospital of Nanjing University of Traditional Chinese Medicine, Nanjing 210017, Jiangsu Province, China
| | - Can Wang
- Anorectal Disease Diagnosis and Treatment Center, Second Affiliated Hospital of Nanjing University of Traditional Chinese Medicine, Nanjing 210017, Jiangsu Province, China
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Fadel MG, Peltola L, Pellino G, Frunza G, Kontovounisios C. The Role of Pudendal Nerve Block in Colorectal Surgery: A Systematic Review. J INVEST SURG 2020; 34:1238-1245. [PMID: 32633163 DOI: 10.1080/08941939.2020.1786611] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
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.
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Affiliation(s)
- Michael G Fadel
- Department of Colorectal Surgery, Chelsea and Westminster Hospital, London, UK
| | - Laura Peltola
- Department of Anaesthesia, Chelsea and Westminster Hospital, London, UK
| | - Gianluca Pellino
- Department of Advanced Medical and Surgical Sciences, Universitá degli Studi della Campania "Luigi Vanvitelli", Naples, Italy.,Department of Colorectal Surgery, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Gabriela Frunza
- Department of Anaesthesia, Chelsea and Westminster Hospital, London, UK
| | - Christos Kontovounisios
- Department of Colorectal Surgery, Chelsea and Westminster Hospital, London, UK.,Department of Colorectal Surgery, Royal Marsden Hospital, London, UK.,Department of Surgery and Cancer, Imperial College, London, UK
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Indraccolo U, Nardulli R, Indraccolo SR. 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. Neurourol Urodyn 2020; 39:890-897. [PMID: 32022321 DOI: 10.1002/nau.24303] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Accepted: 01/17/2020] [Indexed: 12/30/2022]
Abstract
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.
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Affiliation(s)
- Ugo Indraccolo
- Obstetrics and Gynecology Unit, Department of Reproduction and Growth, Azienda Ospedaliero-Universitaria Arcispedale Sant'Anna of Cona, Ferrara, Italy
| | - Roberto Nardulli
- Salvatore Maugeri Foundation-Work and Rehabilitation Clinic. I. R. C. C. S., Cassano delle Murge, Bari, Italy
| | - Salvatore R Indraccolo
- Department of Gynecological and Urological Sciences, "Sapienza" University of Rome, Rome, Italy
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Comparison of Ultrasound-Guided Transgluteal and Finger-Guided Transvaginal Pudendal Nerve Block Techniques: Which One is More Effective? Int Neurourol J 2019; 23:310-320. [PMID: 31905278 PMCID: PMC6944786 DOI: 10.5213/inj.1938112.056] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2018] [Accepted: 01/03/2019] [Indexed: 12/30/2022] Open
Abstract
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.
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Dickson E, Higgins P, Sehgal R, Gorissen K, Jones O, Cunningham C, Hogan AM, Lindsey I. Role of nerve block as a diagnostic tool in pudendal nerve entrapment. ANZ J Surg 2019; 89:695-699. [DOI: 10.1111/ans.15275] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Revised: 04/10/2019] [Accepted: 04/11/2019] [Indexed: 11/30/2022]
Affiliation(s)
- Edward Dickson
- Department of Colorectal SurgeryOxford University Hospital NHS Trust Oxford UK
| | - Patrick Higgins
- Department of Colorectal SurgeryUniversity Hospital Galway Galway Ireland
| | - Rishabh Sehgal
- Department of Colorectal SurgeryUniversity Hospital Galway Galway Ireland
| | - Kim Gorissen
- Department of Colorectal SurgeryOxford University Hospital NHS Trust Oxford UK
| | - Oliver Jones
- Department of Colorectal SurgeryOxford University Hospital NHS Trust Oxford UK
| | - Chris Cunningham
- Department of Colorectal SurgeryOxford University Hospital NHS Trust Oxford UK
| | - Aisling M. Hogan
- Department of Colorectal SurgeryUniversity Hospital Galway Galway Ireland
| | - Ian Lindsey
- Department of Colorectal SurgeryOxford University Hospital NHS Trust Oxford UK
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Vinod K, Kurhekar P, Sharanya K. Randomized trial comparing the incidence of unintended sciatic nerve block following ultrasound-guided pudendal nerve block with two different volumes of ropivacaine for hemorrhoidectomy: A pilot study. INDIAN JOURNAL OF PAIN 2019. [DOI: 10.4103/ijpn.ijpn_60_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Tricard T, Munier P, Story F, Lang H, Saussine C. The drug-resistant pudendal neuralgia management: A systematic review. Neurourol Urodyn 2018; 38:13-21. [DOI: 10.1002/nau.23824] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Accepted: 08/19/2018] [Indexed: 11/09/2022]
Affiliation(s)
- Thibault Tricard
- Department of Urology; NHC Hôpitaux Universitaires de Strasbourg; Strasbourg France
| | - Pierre Munier
- Department of Urology; NHC Hôpitaux Universitaires de Strasbourg; Strasbourg France
| | - Fleur Story
- Department of Urology; NHC Hôpitaux Universitaires de Strasbourg; Strasbourg France
| | - Hervé Lang
- Department of Urology; NHC Hôpitaux Universitaires de Strasbourg; Strasbourg France
| | - Christian Saussine
- Department of Urology; NHC Hôpitaux Universitaires de Strasbourg; Strasbourg France
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Abstract
Postpartum chronic pain is a clinical reality which affects 6.1% to 11.5% of women after delivery and affects their recovery. The large range of incidence observed in the literature relies on criteria used to define chronic postpartum pain. The features depend on the type of delivery. Cesarean delivery which rate is increasing worldwide seems currently associated with lower risk of chronic postpartum pain, specifically chronic pelvic pain. Further chronic scar pain which often involves a neuropathic component is often of mild intensity. In opposite, after vaginal delivery, chronic pelvic pain and perineal pain have an important negative impact on women's mood and quality of life. As for any chronic pain, individual risk factors account more than degree of tissue trauma. From actual reports in the field, better pain education of both women and health care providers might help to reduce the problem.
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Affiliation(s)
- Patricia Lavand'homme
- Department of Anesthesiology, Medical School, St. Luc Hospital, Catholic University of Louvain, Brussels, Belgium -
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Pudendal Neuralgia: Making Sense of a Complex Condition. CURRENT SEXUAL HEALTH REPORTS 2018. [DOI: 10.1007/s11930-018-0177-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Rojas-Gómez MF, Blanco-Dávila R, Tobar Roa V, Gómez González AM, Ortiz Zableh AM, Ortiz Azuero A. Regional anesthesia guided by ultrasound in the pudendal nerve territory. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2017. [DOI: 10.1016/j.rcae.2017.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Anestesia regional guiada por ultrasonido en territorio del nervio pudendo. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2017. [DOI: 10.1016/j.rca.2017.05.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
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Regional anesthesia guided by ultrasound in the pudendal nerve territory☆. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2017. [DOI: 10.1097/01819236-201707000-00006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Carey ET, Till SR, As-Sanie S. Pharmacological Management of Chronic Pelvic Pain in Women. Drugs 2017; 77:285-301. [DOI: 10.1007/s40265-016-0687-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Leone JE, Middleton S. Nontraumatic Testicular Pain due to Sacroiliac-Joint Dysfunction: A Case Report. J Athl Train 2016; 51:651-657. [PMID: 27626835 DOI: 10.4085/1062-6050-51.10.06] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To discuss the case of a 49-year-old man who presented to the sports medicine staff with pelvic pain of 10 years' duration consistent with pudendal neuralgia. BACKGROUND Testicular pain in men is often provoked by direct trauma or may indicate an oncologic process. DIFFERENTIAL DIAGNOSIS Epididymitis, athletic pubalgia, testicular tumor, sacroiliac joint dysfunction, lumbar radiculopathy. TREATMENT The patient responded positively to treatment and rehabilitation to restore normal mechanics to the lumbo-pelvic-hip complex. Several flare-ups since the initial treatment have been of short duration (<2 days) and less intense. UNIQUENESS Pudendal neuralgia tends to affect females more than males due to changes in the alignment and stability of the pelvis from a combination of a shorter, wider pelvis and muscle imbalances associated with childbirth. Typically, males with testicular pain suffer from epididymitis or some type of testicular torsion, which was not the situation in this case. Compression is also a common cause of pudendal neuralgia, although it was not responsible for this patient's pain, making diagnosis and treatment complex. CONCLUSIONS Many pain syndromes can be treated with removal of the original stimulus. However, recognizing the factors contributing to pelvic pain and dysfunction in males can be a challenge for the sports medicine professional. A vigilant and unassuming approach to male pelvic pain is warranted, particularly by health care providers in diverse practice settings.
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Wadhwa V, Scott KM, Rozen S, Starr AJ, Chhabra A. CT-guided Perineural Injections for Chronic Pelvic Pain. Radiographics 2016; 36:1408-25. [DOI: 10.1148/rg.2016150263] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Chhabra A, McKenna CA, Wadhwa V, Thawait GK, Carrino JA, Lees GP, Dellon AL. 3T magnetic resonance neurography of pudendal nerve with cadaveric dissection correlation. World J Radiol 2016; 8:700-706. [PMID: 27551340 PMCID: PMC4965354 DOI: 10.4329/wjr.v8.i7.700] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Revised: 03/25/2016] [Accepted: 05/11/2016] [Indexed: 02/07/2023] Open
Abstract
AIM: To evaluate the pudendal nerve segments that could be identified on magnetic resonance neurography (MRN) before and after surgical marking of different nerve segments.
METHODS: The hypothesis for this study was that pudendal nerve and its branches would be more easily seen after the surgical nerve marking. Institutional board approval was obtained. One male and one female cadaver pelvis were obtained from the anatomy board and were scanned using 3 Tesla MRI scanner using MR neurography sequences. All possible pudendal nerve branches were identified. The cadavers were then sent to the autopsy lab and were surgically dissected by a peripheral nerve surgeon and an anatomist to identify the pudendal nerve branches. Radiological markers were placed along the course of the pudendal nerve and its branches. The cadavers were then closed and rescanned using the same MRN protocol as the pre-marking scan. The remaining pudendal nerve branches were attempted to be identified using the radiological markers. All scans were read by an experienced musculoskeletal radiologist.
RESULTS: The pre-marking MR Neurography scans clearly showed the pudendal nerve at its exit from the lumbosacral plexus in the sciatic notch, at the level of the ischial spine and in the Alcock’s Canal in both cadavers. Additionally, the right hemorrhoidal branch could be identified in the male pelvis cadaver. The perineal and distal genital branches could not be identified. On post-marking scans, the markers were used as identifiable structures. The location of the perineal branch, the hemorroidal branch and the dorsal nerve to penis (in male cadaver)/clitoris (in female cadaver) could be seen. However, the visualization of these branches was suboptimal. The contralateral corresponding nerves were poorly seen despite marking on the surgical side. The nerve was best seen on axial T1W and T2W SPAIR images. The proximal segment could be seen well on 3D DW PSIF sequence. T2W SPACE was not very useful in visualization of this small nerve or its branches.
CONCLUSION: Proximal pudendal nerve is easily seen on MR neurography, however it is not possible to identify distal branches of the pudendal nerve even after surgical marking.
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Labat JJ, Riant T, Lassaux A, Rioult B, Rabischong B, Khalfallah M, Volteau C, Leroi AM, Ploteau S. Adding corticosteroids to the pudendal nerve block for pudendal neuralgia: a randomised, double-blind, controlled trial. BJOG 2016; 124:251-260. [PMID: 27465823 PMCID: PMC5215631 DOI: 10.1111/1471-0528.14222] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/07/2016] [Indexed: 11/30/2022]
Abstract
Objective To compare the effect of corticosteroids combined with local anaesthetic versus local anaesthetic alone during infiltrations of the pudendal nerve for pudendal nerve entrapment. Design Randomised, double‐blind, controlled trial. Setting Multicentre study. Population 201 patients were included in the study, with a subgroup of 122 women. Methods CT‐guided pudendal nerve infiltrations were performed in the sacrospinous ligament and Alcock's canal. There were three study arms: patients in Arm A (n = 68) had local anaesthetic alone, those in Arm B (n = 66) had local anaesthetic plus corticosteroid and those in Arm C (n = 67) local anaesthetic plus corticosteroid with a large volume of normal saline. Main outcome measures The primary end‐point was the pain intensity score at 3 months. Patients were regarded as responders (at least a 30‐point improvement on a 100‐point visual analogue scale of mean maximum pain over a 2‐week period) or nonresponders. Results Three months’ postinfiltration, 11.8% of patients in the local anaesthetic only arm (Arm A) were responders versus 14.3% in the local anaesthetic plus corticosteroid arms (Arms B and C). This difference was not statistically significant (P = 0.62). No statistically significant difference was observed in the female subgroup between Arm A and Arms B and C (P = 0.09). No significant difference was detected for the various pain assessment procedures, functional criteria or quality‐of‐life criteria. Conclusions Corticosteroids provide no additional therapeutic benefits compared with local anaesthetic and should therefore no longer be used. Tweetable abstract Steroid infiltrations do not improve the results of local anaesthetic infiltrations in pudendal neuralgia. Steroid infiltrations do not improve the results of local anaesthetic infiltrations in pudendal neuralgia.
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Affiliation(s)
- J J Labat
- Federative Centre of Pelvi-Perineology, CHU Nantes, Nantes, France
| | - T Riant
- Federative Centre of Pelvi-Perineology, CHU Nantes, Nantes, France.,Pain Unit, Centre Catherine de Sienne, Nantes, France
| | - A Lassaux
- Pain Clinic, Hôpital Rothschild, Paris, France
| | - B Rioult
- Pain Unit, Centre Catherine de Sienne, Nantes, France
| | - B Rabischong
- Gynaecology Department, Polyclinique Hôtel-Dieu, Clermont-Ferrand, France
| | - M Khalfallah
- Centre Hospitalier de la Cote Basque, Bayonne, France
| | | | - A-M Leroi
- Digestive Physiology Department, Hôpital Charles Nicolle, Rouen, France
| | - S Ploteau
- Federative Centre of Pelvi-Perineology, CHU Nantes, Nantes, France.,Gynaecology Department, Hôtel-Dieu, Nantes, France
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Emhardt E, Siegel J, Hoffman L. Anatomic variation and orgasm: Could variations in anatomy explain differences in orgasmic success? Clin Anat 2016; 29:665-72. [PMID: 26916103 DOI: 10.1002/ca.22703] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2015] [Revised: 02/16/2016] [Accepted: 02/16/2016] [Indexed: 01/18/2023]
Abstract
Though the public consciousness is typically focused on factors such as psychology, penis size, and the presence of the "G-spot," there are other anatomical and neuro-anatomic differences that could play an equal, or more important, role in the frequency and intensity of orgasms. Discovering these variations could direct further medical or procedural management to improve sexual satisfaction. The aim of this study is to review the available literature of anatomical sexual variation and to explain why this variation may predispose some patients toward a particular sexual experience. In this review, we explored the available literature on sexual anatomy and neuro-anatomy. We used PubMed and OVID Medline for search terms, including orgasm, penile size variation, clitoral variation, Grafenberg spot, and benefits of orgasm. First we review the basic anatomy and innervation of the reproductive organs. Then we describe several anatomical variations that likely play a superior role to popular known variation (penis size, presence of g-spot, etc). For males, the delicate play between the parasympathetic and sympathetic nervous systems is vital to achieve orgasm. For females, the autonomic component is more complex. The clitoris is the primary anatomical feature for female orgasm, including its migration toward the anterior vaginal wall. In conclusions, orgasms are complex phenomena involving psychological, physiological, and anatomic variation. While these variations predispose people to certain sexual function, future research should explore how to surgically or medically alter these. Clin. Anat. 29:665-672, 2016. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- E Emhardt
- Class of 2016, Indiana University School of Medicine, Indianapolis, Indiana, 46220
| | - J Siegel
- Department of Neurology, Mayo Clinic, Jacksonville, Florida, 32224
| | - L Hoffman
- Department of Anatomy, Indiana University School of Medicine, Fort Wayne, Indiana, 46805
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Turmo M, Echevarria M, Rubio P, Almeida C. Development of chronic pain after episiotomy. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2015; 62:436-442. [PMID: 25555717 DOI: 10.1016/j.redar.2014.10.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/09/2014] [Revised: 10/04/2014] [Accepted: 10/10/2014] [Indexed: 06/04/2023]
Abstract
OBJECTIVE To analyze the incidence of chronic pain 5 months after episiotomy, as well as potential prognostic factors. METHODS A prospective cohort observational study was conducted on pregnant women age≥18 years who had undergone an episiotomy. The presence of pain was evaluated in the area of episiotomy at 24 and 48 h of delivery using a structured face-to-face questionnaire, and by telephone questionnaire at 5 months. The primary endpoint was the presence of persistent pain at 5 months. A record was made of the presence of pain at delivery, and its intensity, the presence or absence of epidural analgesia, instrumental delivery, perineal tear, and pain when episiotomy was performed, as well as the presence of dyspareunia and urinary incontinence at 5 months post-episiotomy. RESULTS A total of 87 parturient patients were included, of whom 78 completed the study. Of the patients who completed the study, 12.8% reported chronic episiotomy pain. Epidural analgesia was associated with a higher incidence of instrumental delivery and less pain at the time of episiotomy and expulsion (P<.0005, P<.02, and P<.01, respectively). Chronic pain is associated with operative delivery (P<.017), and with the presence of pain at rest at 24 and 48 h (P<.01), of wound complications (P<.026), and of dyspareunia (P<.001). CONCLUSION An incidence of 12.8% of women developing chronic pain after delivery with episiotomy suggests a health problem. More studies are needed to confirm our results.
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Affiliation(s)
- M Turmo
- Servicio de Anestesiología y Reanimación, Unidad de Investigación, Hospital de Valme, Sevilla, España
| | - M Echevarria
- Servicio de Anestesiología y Reanimación, Unidad de Investigación, Hospital de Valme, Sevilla, España.
| | - P Rubio
- Servicio de Anestesiología y Reanimación, Unidad de Investigación, Hospital de Valme, Sevilla, España
| | - C Almeida
- Servicio de Anestesiología y Reanimación, Unidad de Investigación, Hospital de Valme, Sevilla, España
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Prologo JD, Lin RC, Williams R, Corn D. Percutaneous CT-guided cryoablation for the treatment of refractory pudendal neuralgia. Skeletal Radiol 2015; 44:709-14. [PMID: 25511935 DOI: 10.1007/s00256-014-2075-3] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2014] [Revised: 11/25/2014] [Accepted: 11/26/2014] [Indexed: 02/02/2023]
Abstract
PURPOSE To evaluate the safety and efficacy of percutaneous CT-guided cryoablation of the pudendal nerve for the treatment of refractory pudendal neuralgia. MATERIALS AND METHODS Eleven patients were selected to undergo percutaneous CT-guided cryoablation of the pudendal nerve based on established diagnostic criteria. Brief Pain Inventory questionnaires were administered prior to the procedure, during the immediate 24 h post procedure, and 45 days and 6 months following the procedure. RESULTS Prior to treatment, the average level of pain on a scale from 0 (no pain) to 10 (worst pain imaginable) was 7.6, with pain described as "burning" (80%), "pulling" (37.5%), "crushing" (50%), "pressure" (84.5%), "throbbing" (50%), "knife-life" (52%), and "other" (60%). At 24 h, 45 days, and 6 months post-treatment, pain intensity dropped to 2.6, 3.5, and 3.1, respectively (p < 0.005). There were no procedure-related complications. CONCLUSIONS CT-guided percutaneous cryoablation may represent a safe and efficacious option for selected patients with refractory pudendal neuralgia.
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Affiliation(s)
- J David Prologo
- Department of Radiology and Imaging Sciences Division of Interventional Radiology and Image-Guided Medicine, Emory University Hospital, 1364 Clifton Road, NE Suite D112, Atlanta, GA, 30322, USA,
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PETERS KM, KILLINGER KA, JAEGER C, CHEN C. Pilot Study Exploring Chronic Pudendal Neuromodulation as a Treatment Option for Pain Associated with Pudendal Neuralgia. Low Urin Tract Symptoms 2014; 7:138-42. [DOI: 10.1111/luts.12066] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2014] [Revised: 03/31/2014] [Accepted: 05/07/2014] [Indexed: 11/30/2022]
Affiliation(s)
- Kenneth M. PETERS
- Department of Urology; Oakland University William Beaumont School of Medicine; Rochester Michigan USA
- Beaumont Health System; Royal Oak Michigan USA
| | | | - Christopher JAEGER
- Department of Urology; Oakland University William Beaumont School of Medicine; Rochester Michigan USA
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Beco J, Seidel L, Albert A. Normative values of skin temperature and thermal sensory thresholds in the pudendal nerve territory. Neurourol Urodyn 2014; 34:571-7. [PMID: 24782126 DOI: 10.1002/nau.22614] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2013] [Accepted: 03/26/2014] [Indexed: 11/08/2022]
Abstract
AIMS The aim of this study was to define normative values of skin temperature and thermal sensory threshold in the pudendal nerve territory. METHODS Warm and cold detection thresholds (using the method of limits) and skin temperature were measured in a group of 41 presumably healthy female volunteers aged 41 years (range: 23-66 years) at left thenar eminence and in the pudendal nerve territory. Outlying data were discarded and 95% normative values were derived assuming Normal distributions. RESULTS Room temperature averaged 24.3 ± 1.1°. Skin temperature and cold detection threshold value were greater anteriorly (clitoris, labia) than posteriorly (para-anal). Para-anal skin temperature and cold detection threshold value were also significantly lower on the right side than on the left side. The warm detection threshold was significantly lower at the clitoris level than at left and right labia. A significant positive effect of skin temperature on cold and warm detection thresholds values was noted especially at thenar and para-anal levels. Age had no effect on skin temperature but warm detection thresholds at clitoris were higher in older subjects. The only qualitative abnormalities observed were after-sensation (4.9%) and habituation (2.8%). Allodynia, dysesthesia, radiation, and dyslocalization were not observed. Two-sided normative values were determined for skin temperature, vertical, and horizontal differences, while one-sided values were derived for cold and warm detection thresholds as well as for their difference. CONCLUSIONS Normative values for perineal skin temperature and thermal detection thresholds can be used as an alternative non-invasive way to evaluate pudendal neuropathy.
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Affiliation(s)
- Jacques Beco
- Department of Gynecology, University Hospital of Liège (CHU), Liège, Belgium.,Sainte Elisabeth Hospital (CHC), Heusy, Belgium
| | - Laurence Seidel
- Medical Informatics and Biostatistics, University Hospital of Liège (CHU), Liège, Belgium
| | - Adelin Albert
- Medical Informatics and Biostatistics, University Hospital of Liège (CHU), Liège, Belgium
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CT-guided percutaneous pulse-dose radiofrequency for pudendal neuralgia. Cardiovasc Intervent Radiol 2013; 37:476-81. [PMID: 23963376 DOI: 10.1007/s00270-013-0679-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2013] [Accepted: 05/21/2013] [Indexed: 10/26/2022]
Abstract
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.
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