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Piñeiro-Franco L, Alonso-Calvete A, Da Cuña-Carrera I. Management of pudendal neuralgia with electrical stimulation. A systematic review. Actas Urol Esp 2024; 48:416-426. [PMID: 38365090 DOI: 10.1016/j.acuroe.2024.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 01/09/2024] [Indexed: 02/18/2024]
Abstract
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.
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Affiliation(s)
- L Piñeiro-Franco
- Facultad de Fisioterapia, Universidad de Vigo, Vigo, Pontevedra, Spain
| | - A Alonso-Calvete
- Facultad de Fisioterapia, Universidad de Vigo, Vigo, Pontevedra, Spain.
| | - Iria Da Cuña-Carrera
- Facultad de Fisioterapia, Universidad de Vigo, Vigo, Pontevedra, Spain; Grupo de Investigación Fisioterapia Clínica (FS1), Instituto de Investigación Sanitaria Galicia Sur (IIS Galicia Sur), SERGAS-UVIGO, Galicia, España
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Mylle T, De Corte R, Hervé F, Everaert K, Bou Kheir G. Surgical approaches for pudendal nerve entrapment: insights from a systematic review and meta-analysis. Surg Endosc 2024:10.1007/s00464-024-10990-w. [PMID: 38942945 DOI: 10.1007/s00464-024-10990-w] [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: 02/20/2024] [Accepted: 06/08/2024] [Indexed: 06/30/2024]
Abstract
BACKGROUND Pudendal nerve entrapment (PNE) is an underdiagnosed condition affecting a spectrum of pelvic functions, primarily pain, as outlined by Nantes diagnostic criteria. Although numerous surgical decompression techniques are available for its management, consensus on efficacy and safety is lacking. This study conducts a systematic review and meta-analysis to assess the efficacy and complication rates of the main surgical decompression techniques. METHODS A comprehensive literature search was conducted in PubMed®, Embase®, Web of Science®, and ClinicalTrails.gov® on 19th of April 2023. Initial screening involved title and abstract evaluation, with subsequent retrieval and assessment of abstracts and full-text articles. Studies assessing pain outcomes before and after surgical release of the pudendal nerve were included. Studies without full-text, focusing on diagnostic methods or with outcomes relating solely to LUTS, digestive symptoms, or sexual dysfunction, were excluded. Risk of bias assessement was conducted using the National Institute of Health (NIH) Study Quality Assessment tool. Studies were categorized based on three surgical techniques: perineal, transgluteal, and laparoscopic transperitoneal. Random-effects meta-analysis with subgroup analysis were used. Meta-regression analyses were conducted to investigate the influence of covariates on the observed outcomes. RESULTS Nineteen studies, comprising 810 patients, were included. The overall significant pain relief rate across all techniques was estimated at 0.67 (95% CI 0.54 to 0.78) with considerable heterogeneity (I2 = 80.4%). Subgroup analysis revealed success rate for different techniques: laparoscopic (0.91, 95% CI 0.64 to 0.98), perineal (0.69, 95% CI 0.52 to 0.82), and transgluteal (0.50, 95% CI 0.37 to 0.63). The laparoscopic technique exhibited a complication rate of 16.0%. Meta-regression indicated that patient age and median follow-up significantly influenced outcomes. CONCLUSION While comparing surgical techniques is challenging, this meta-analysis highlights important outcome differences. The laparoscopic technique appears most promising for pain improvement. However, the study also emphasizes the need for further robust, long-term research due to significant heterogeneity across studies and prevelent risk of bias. PROSPERO database: CRD42023496564.
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Affiliation(s)
- Toon Mylle
- Department of Urology, ERN Accredited Centre, Ghent University Hospital, Corneel Heymanslaan 10, 9000, Ghent, Belgium.
| | - René De Corte
- Department of Urology, ERN Accredited Centre, Ghent University Hospital, Corneel Heymanslaan 10, 9000, Ghent, Belgium
| | - François Hervé
- Department of Urology, ERN Accredited Centre, Ghent University Hospital, Corneel Heymanslaan 10, 9000, Ghent, Belgium
| | - Karel Everaert
- Department of Urology, ERN Accredited Centre, Ghent University Hospital, Corneel Heymanslaan 10, 9000, Ghent, Belgium
| | - George Bou Kheir
- Department of Urology, ERN Accredited Centre, Ghent University Hospital, Corneel Heymanslaan 10, 9000, Ghent, Belgium
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Giulioni C, Pitoni L, Fuligni D, Beltrami M, Passarella V, Palantrani V, De Stefano V, Castellani D, Galosi AB. Pudendal nerve neurolysis outcomes for urogenital and rectal disorders in patients suffering from pudendal nerve entrapment: A systematic review. Investig Clin Urol 2024; 65:230-239. [PMID: 38714513 PMCID: PMC11076799 DOI: 10.4111/icu.20230402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Revised: 01/28/2024] [Accepted: 02/15/2024] [Indexed: 05/10/2024] Open
Abstract
PURPOSE Pudendal neuropathy is an uncommon condition that exhibits several symptoms depending on the site of nerve entrapment. This study aims to evaluate the efficacy of pudendal nerve neurolysis (PNN) in improving lower urinary tract symptoms, anal and/or urinary incontinence, and sexual dysfunctions. MATERIALS AND METHODS A systematic literature search was performed on 20 May 2023 using Scopus, PubMed, and Embase. Only English and adult papers were included. Meeting abstracts and preclinical studies were excluded. RESULTS Twenty-one papers were accepted, revealing significant findings in the field. The study identified four primary sites of pudendal nerve entrapment (PNE), with the most prevalent location likely being at the level of the Alcock canal. Voiding symptoms are commonly exhibited in patients with PNE. PNN improved both urgency and voiding symptoms, and urinary and anal incontinence but is less effective in cases of long-standing entrapment. Regarding sexual function, the recovery of the somatic afferent pathway results in an improvement in erectile function early after neurolysis. Complete relief of persistent genital arousal disorder occurs in women, although bilateral PNN is necessary to achieve the efficacy. PNN is associated with low-grade complications. CONCLUSIONS PNN emerges as a viable option for addressing urinary symptoms, fecal incontinence, erectile dysfunction, and female sexual arousal in patients suffering from PNE with minimal postoperative morbidity.
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Affiliation(s)
- Carlo Giulioni
- Urology Unit, Azienda Ospedaliero-Universitaria delle Marche, Polytechnic University of Marche, Ancona, Italy.
| | - Lucia Pitoni
- Urology Unit, Azienda Ospedaliero-Universitaria delle Marche, Polytechnic University of Marche, Ancona, Italy
| | - Demetra Fuligni
- Urology Unit, Azienda Ospedaliero-Universitaria delle Marche, Polytechnic University of Marche, Ancona, Italy
| | - Mattia Beltrami
- Urology Unit, Azienda Ospedaliero-Universitaria delle Marche, Polytechnic University of Marche, Ancona, Italy
| | - Valeria Passarella
- Urology Unit, Azienda Ospedaliero-Universitaria delle Marche, Polytechnic University of Marche, Ancona, Italy
| | - Vanessa Palantrani
- Urology Unit, Azienda Ospedaliero-Universitaria delle Marche, Polytechnic University of Marche, Ancona, Italy
| | - Virgilio De Stefano
- Urology Unit, Azienda Ospedaliero-Universitaria delle Marche, Polytechnic University of Marche, Ancona, Italy
| | - Daniele Castellani
- Urology Unit, Azienda Ospedaliero-Universitaria delle Marche, Polytechnic University of Marche, Ancona, Italy
| | - Andrea Benedetto Galosi
- Urology Unit, Azienda Ospedaliero-Universitaria delle Marche, Polytechnic University of Marche, Ancona, Italy
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Giulioni C, Pirola GM, Maggi M, Pitoni L, Fuligni D, Beltrami M, Palantrani V, De Stefano V, Maurizi V, Castellani D, Galosi AB. Pudendal Nerve Neurolysis in Patients Afflicted With Pudendal Nerve Entrapment: A Systematic Review of Surgical Techniques and Their Efficacy. Int Neurourol J 2024; 28:11-21. [PMID: 38569616 PMCID: PMC10990758 DOI: 10.5213/inj.2448010.005] [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: 12/21/2023] [Accepted: 02/04/2024] [Indexed: 04/05/2024] Open
Abstract
To assess the effectiveness and safety of various techniques of pudendal nerve neurolysis (PNN) in patients with pudendal nerve entrapment (PNE). A comprehensive literature search was conducted on May 20th, 2023, using Scopus, PubMed, and Embase databases. Only studies in English involving adults were accepted, while meeting abstracts and preclinical studies were excluded. A total of 34 papers were included. Transperineal PNN emerged as a promising technique, demonstrating significant potential in alleviating pain, restoring erectile function in males, and improving the resolution of urinary stress incontinence in females. Furthermore, the bilateral approach consistently yielded positive outcomes in addressing urinary symptoms. The transgluteal technique appeared particularly suitable for cases of posterior PNE, situated between the sacrospinous ligament and the lesser sciatic foramen. A progressive amelioration of painful symptoms was observed during follow-up. Minimally invasive PNN is evolving and enables decompression along the entire proximal tract up to the Alcock canal, minimizing the risk of comorbidities. In addition to reducing pudendal neuralgia, robot-assisted and laparoscopic approaches determined a reduction in lower urinary tract symptoms and an improvement in erectile function, though further studies are required to corroborate these findings. PNN emerges as an effective treatment for PNE with minimal morbidity. Therefore, PNN should be tailored according to the site of PNE to enhance functional outcomes and improve patient quality of life.
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Affiliation(s)
- Carlo Giulioni
- Urology Unit, Azienda Ospedaliero-Universitaria delle Marche, Polytechnic University of Marche, Ancona, Italy
| | | | - Martina Maggi
- Department of Maternal-Infant and Urological Sciences, Umberto I Polyclinic Hospital, Sapienza University, Rome, Italy
| | - Lucia Pitoni
- Urology Unit, Azienda Ospedaliero-Universitaria delle Marche, Polytechnic University of Marche, Ancona, Italy
| | - Demetra Fuligni
- Urology Unit, Azienda Ospedaliero-Universitaria delle Marche, Polytechnic University of Marche, Ancona, Italy
| | - Mattia Beltrami
- Urology Unit, Azienda Ospedaliero-Universitaria delle Marche, Polytechnic University of Marche, Ancona, Italy
| | - Vanessa Palantrani
- Urology Unit, Azienda Ospedaliero-Universitaria delle Marche, Polytechnic University of Marche, Ancona, Italy
| | - Virgilio De Stefano
- Urology Unit, Azienda Ospedaliero-Universitaria delle Marche, Polytechnic University of Marche, Ancona, Italy
| | - Valentina Maurizi
- Department of Clinical and Molecular Sciences, Ospedaliero-Universitaria delle Marche, Polytechnic University of Marche, Ancona, Italy
| | - Daniele Castellani
- Urology Unit, Azienda Ospedaliero-Universitaria delle Marche, Polytechnic University of Marche, Ancona, Italy
| | - Andrea Benedetto Galosi
- Urology Unit, Azienda Ospedaliero-Universitaria delle Marche, Polytechnic University of Marche, Ancona, Italy
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Carolus A, Uerschels AK. [Rare nerve compression neuropathies]. HANDCHIR MIKROCHIR P 2024; 56:21-31. [PMID: 38508204 DOI: 10.1055/a-2250-8389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/22/2024] Open
Abstract
UNCOMMON NERVE COMPRESSION SYNDROMES In regard to the complex anatomical relationship of peripheral nerves and muscles, tendons, fasciae as well as their long course within those anatomical structures and additional close contact to bony structures, they are prone to suffer from local compression syndromes. Hence creating a vast majority of entrapment syndromes - well described in literature for almost every single nerve. The purpose of this article is to give an overview of symptoms, signs, diagnostic studies and treatment options, addressing especially the less known syndromes. Compression syndromes of the upper arm and shoulder region include the suprascapular nerve syndrome the compression of the axillary nerve within the spatium quadrilaterale and the compression of the long thoracic nerve at the chest wall. The upper extremity offers a variety of infrequent entrapment syndromes, as the pronator teres syndrome and anterior interosseus syndrome, both resulting from pressure to the median nerve in the forearm. Compression neuropathy in the course of the radial nerve in the distal upper extremity is also known as supinator syndrome. Guyon's canal syndrome is the ulnar side equivalent to the well-known carpal tunnel syndrome. In the case of a Cheiralgia paresthetica, a compression of a sensory branch of the superficial radial nerve can be seen. In the lower extremities, a variety of nerves especially in the groin and thigh area can be compressed as they pass through the narrow spaces between the abdominal muscles or underneath the inguinal ligament. Compression of the lateral femoral cutaneous nerve is the most common syndrome. Compression syndromes of the femoral and obturator nerves are most often iatrogenic. Pain around the knee, especially the lateral part and following orthopedic procedures of the knee, can arise from a compression or a lesion of a small infrapatellar branch of the saphenous nerve. Another probably underdiagnosed syndrome is piriformis syndrome, resulting from an entrapment of the sciatic nerve as it passes through certain muscular structures. In the distal lower extremity, the peroneal and tibial nerves can be compressed at multple sites, clinically known as peroneal nerve paralysis resulting from nerve compression around the fibular head, the anterior and posterior tarsal tunnel syndrome, and Morton's metatarsalgia.
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Affiliation(s)
- Anne Carolus
- Neurochirurgie, Evangelisches Jung Stilling Krankenhaus GmbH, Siegen, Germany
- Neurochirurgie, Universitätsklinikum Essen, Essen, Germany
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Bello JSR, Moscote-Salazar LR, Florez-Perdomo WA, Lugo CMR, Hanna A. YouTube and pudendal neuralgia: Is it a good source of information for patients? Clin Neurol Neurosurg 2023; 233:107965. [PMID: 37738937 DOI: 10.1016/j.clineuro.2023.107965] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 09/03/2023] [Accepted: 09/06/2023] [Indexed: 09/24/2023]
Abstract
OBJECTIVE This study aims to identify the shortcomings and quality content of YouTube videos and its effectiveness as a source of patient information on pudendal neuralgia treatment. METHODS A search was conducted on YouTube using the words "pudendal neuralgia physical therapy," "medications for pudendal neuralgia," "pudendal nerve block," "pudendal neuralgia surgery," and "alternative treatments for pudendal neuralgia." The results were analyzed based on the source, general descriptive statistics, the intended audience, and five content areas. The DISCERN scoring system was used to evaluate the quality of videos. RESULTS After the search, 73 videos met the inclusion criteria for further analysis. The majority of these videos (61.64%) were intended to target the general population, whereas a smaller percentage were identified as professional (41.10%) or targeted for physicians (35.62%). From the videos included, 10 (13.70%) described treatment options in a balanced and evidence-based manner. The higher DISCERN score positively correlated with the presence of this last content criterion. With a total DISCERN mean score of 35.42, a significant proportion of the videos (41.10%) were rated very poor. The remaining videos were classified as poor (23.29%), fair (19.18%), good (8.22%), and excellent (8.22%). CONCLUSION The quality of the information included in YouTube videos regarding pudendal neuralgia treatment was considered generally poor. Healthcare providers must recognize the potential influence of this platform on patients' understanding of pudendal neuralgia treatment. There is a need for additional research and randomized studies regarding YouTube content about this condition.
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Affiliation(s)
| | | | | | - Claudia Marcela Restrepo Lugo
- Department of Research Colombian Clinical Research Group in Neurocritical Care, Bogotá, Colombia; Department of Neurosurgery, Hospital Federico Lleras Acosta, Ibague, Colombia
| | - Amgad Hanna
- Department of Biomedical Engineering and Neurological Surgery, University of Wisconsin, Madison, WI, USA
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Habib N, Centini G, Klebanoff JS, Fernandes R, Giorgi M, Moawad GN, Bakar J. Pudendal Neuralgia: Two case reports with laparoscopic nerve decompression. Facts Views Vis Obgyn 2023; 15:181-187. [PMID: 37436058 PMCID: PMC10410660 DOI: 10.52054/fvvo.15.2.073] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/13/2023] Open
Abstract
Pudendal neuralgia (PN) is a rare and underestimated condition. The reported incidence by the International Pudendal Neuropathy Association is 1/100000. However, the actual rate may be significantly higher, with a propensity for women. It is most frequently caused by an entrapment of the nerve at the level of the sacrospinous and sacrotuberous ligament, also known as pudendal nerve entrapment syndrome. Due to the late diagnosis and inadequate management, pudendal nerve entrapment syndrome often leads to considerable reduction in the quality of life and high health care costs. The diagnosis is made using Nantes Criteria, in conjunction with the patient's clinical history and physical findings. Clinical examination with an accurate assessment of the territory of the neuropathic pain is mandatory to set the therapeutic strategy. The aim of the treatment is to control the symptoms and it usually starts with conservative approaches which include analgesics, anticonvulsants, and muscle relaxants. Surgical nerve decompression can be proposed after failure of conservative management. The laparoscopic approach is a feasible and appropriate technique to explore and decompress the pudendal nerve, and to rule out other pelvic conditions that can cause similar symptomatology. In this paper, the clinical history of two patients affected by compressive PN is reported. Both patients underwent laparoscopic pudendal neurolysis suggesting that the treatment for PN should be individualised and carried out by a multidisciplinary team. When conservative treatment fails, laparoscopic nerve exploration and decompression is an adequate option to propose and should be performed by a trained surgeon.
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Jiamjunyasiri A, Tsutsumi M, Muro S, Akita K. Origin, course, and distribution of the posterior femoral cutaneous nerve and the spatial relationship among its branches. Anat Sci Int 2023:10.1007/s12565-023-00721-x. [PMID: 37017904 PMCID: PMC10366308 DOI: 10.1007/s12565-023-00721-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Accepted: 03/31/2023] [Indexed: 04/06/2023]
Abstract
This study aimed to elucidate the origin, course, and distribution of the branches of the posterior femoral cutaneous nerve, considering the segmental and dorsoventral compositions of the sacral plexus, including the pudendal nerve. The buttocks and thighs of five cadavers were analyzed bilaterally. The branches emerged from the sacral plexus, which was divided dorsally to ventrally into the superior gluteal, inferior gluteal, common peroneal, tibial, and pudendal nerves. It descended lateral to the ischial tuberosity and comprised the thigh, gluteal, and perineal branches. As for the thigh and gluteal branches, the dorsoventral order of those originating from the sacral plexus corresponded to the lateromedial order of their distribution. However, the dorsoventral boundary was displaced at the inferior margin of the gluteus maximus between the thigh and gluteal branches. The perineal branch originated from the ventral branch of the nerve roots. In addition, the pudendal nerve branches, which ran medially to the ischial tuberosity, were distributed in the medial part of the inferior gluteal region. These branches should be distinguished from the gluteal branches; the former should be classified as the medial inferior cluneal nerves and the latter as the lateral ones. Finally, the medial part of the inferior gluteal region was distributed by branches of the dorsal sacral rami, which may correspond to the medial cluneal nerves. Thus, the composition of the posterior femoral cutaneous nerve is considered necessary when considering the dorsoventral relationships of the sacral plexus and boundaries of the dorsal and ventral rami.
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Affiliation(s)
- Areeya Jiamjunyasiri
- Department of Clinical Anatomy, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Yushima 1-5-45, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Masahiro Tsutsumi
- Department of Clinical Anatomy, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Yushima 1-5-45, Bunkyo-ku, Tokyo, 113-8519, Japan
- Inclusive Medical Sciences Research Institute, Morinomiya University of Medical Sciences, Osaka, Japan
| | - Satoru Muro
- Department of Clinical Anatomy, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Yushima 1-5-45, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Keiichi Akita
- Department of Clinical Anatomy, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Yushima 1-5-45, Bunkyo-ku, Tokyo, 113-8519, Japan.
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Wang CL, Song T. The Clinical Efficacy of High-Voltage Long-Duration Pulsed Radiofrequency Treatment in Pudendal Neuralgia: A Retrospective Study. Neuromodulation 2022; 25:1372-1377. [PMID: 33945192 DOI: 10.1111/ner.13401] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 03/11/2021] [Accepted: 03/23/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND Patients with pudendal neuralgia (PN) experience long-lasting chronic pain, hyperalgesia, and comorbid emotional disorders, such as depression and anxiety. Treatment via conventional pulsed radiofrequency (PRF) current carries a significantly high rate of failure. OBJECTIVE To determine the safety and clinical efficacy of high-voltage, long-duration PRF application to the pudendal nerve in patients with PN. STUDY DESIGN Observational retrospective design, self before-after controlled clinical trial. MATERIALS AND METHODS We analyzed the records of 70 patients of our hospital with diagnosed PN. Treatment consisted of PRF application to the pudendal nerve, using computed tomography guidance to target the pudendal nerve at the level of the ischial spine or ischial tuberosity of the affected side. PRF was applied with the following parameters: temperature 42 °C, frequency 2 Hz, pulse width 20 ms, field intensity ramped gradually from 40 to 90 V, duration 900 sec. The therapeutic effect was evaluated by collecting patient scores for the visual analog scale (VAS), SF-36 health survey questionnaire (SF-36), and patient health questionnaire (PHQ-9) before treatment and at 1-, 4-, and 12-week follow-ups after PRF treatment. Data were analyzed by paired t-test with p < 0.05 considered to be statistically significant. RESULTS VAS, SF-36, and PHQ-9 scores at 1, 4, and 12 weeks after high-voltage long-duration PRF treatment were significantly improved relative to their respective pretreatment baseline scores (p < 0.05 for all). The effective rate at 12 weeks after high-voltage long-duration PRF was up to 88.6%. LIMITATIONS A small sample size and lack of a control group. CONCLUSIONS High-voltage long-duration PRF provided significant short-term (at least 12 weeks) pain relief to most patients with PN; it also improved subjective measures of depression and quality of life over the same duration of time.
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Affiliation(s)
- Cheng-Long Wang
- Department of Pain Medicine, the First Affiliated Hospital, China Medical University, Shenyang, China
| | - Tao Song
- Department of Pain Medicine, the First Affiliated Hospital, China Medical University, Shenyang, China.
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Khalife T, Hagen AM, Alm JEC. Retroperitoneal Causes of Genitourinary Pain Syndromes: Systematic Approach to Evaluation and Management. Sex Med Rev 2022; 10:529-542. [PMID: 37051972 DOI: 10.1016/j.sxmr.2022.06.009] [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: 03/14/2022] [Revised: 06/13/2022] [Accepted: 06/24/2022] [Indexed: 10/14/2022]
Abstract
INTRODUCTION Women with pelvic pain commonly report pain in their ovaries, vagina, uterus, or bladder. These symptoms may be caused by visceral genitourinary pain syndromes but also may be caused by musculoskeletal disorders of the abdomen and pelvis. Understanding neuroanatomical and musculoskeletal factors that may contribute to genitourinary pain is important for evaluation and management. OBJECTIVES This review aims to (i) highlight the importance of clinical knowledge of pelvic neuroanatomy and sensory dermatomal distribution of the lower abdomen, pelvis, and lower extremities, exemplified in a clinical case; (ii) review common neuropathic and musculoskeletal causes of acute and chronic pelvic pain that may be challenging to diagnose and manage; and (iii) discuss female genitourinary pain syndromes with a focus on retroperitoneal causes and treatment options. METHODS A comprehensive review of the literature was performed by searching the PubMed, Ovid Embase, MEDLINE, and Scopus databases using the keywords "chronic pelvic pain," "neuropathy," "neuropathic pain," "retroperitoneal schwannoma," "pudendal neuralgia," and "entrapment syndromes." RESULTS Retroperitoneal causes of genitourinary pain syndromes have substantial overlap with common conditions treated in a primary care setting. Thus, a comprehensive and systematic history and physical examination, with focused attention to the pelvic neuroanatomy, is key to establishing the correct diagnosis. In the clinical case, such a comprehensive approach led to the unexpected finding of a large retroperitoneal schwannoma. This case highlights the intricacy of pelvic pain syndromes and the complex nature of their possible overlapping causes, which ultimately affects treatment planning. CONCLUSION Knowledge of the neuroanatomy and neurodermatomes of the abdomen and pelvis, in addition to understanding pain pathophysiology, is critical when evaluating patients with pelvic pain. Failure to apply proper evaluation and implement proper multidisciplinary management strategies contributes to unnecessary patient distress, decreased quality of life, and increased use of health care services. Khalife T, Hagen AM, Alm JEC. Retroperitoneal Causes of Genitourinary Pain Syndromes: Systematic Approach to Evaluation and Management. Sex Med Rev 2022;XX:XXX-XXX.
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Affiliation(s)
- Tarek Khalife
- Obstetrics and Gynecology, Mayo Clinic Health System - Southwest Minnesota region, Mankato, MN, USA.
| | - Amy M Hagen
- Obstetrics and Gynecology, Mayo Clinic Health System - Southwest Minnesota region, Mankato, MN, USA
| | - Jessica E C Alm
- Physical Medicine and Rehabilitation, Mayo Clinic Health System - Southwest Minnesota region, Mankato, MN, USA
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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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12
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Lo L, Duarte A, Bencardino JT. Nerve Entrapments in the Pelvis and Hip. Semin Musculoskelet Radiol 2022; 26:153-162. [PMID: 35609576 DOI: 10.1055/s-0042-1750211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Clinical symptoms of pelvic entrapment neuropathies are widely variable and frequently nonspecific, thus rendering it difficult to localize and diagnose. Magnetic resonance imaging (MRI), and in particular MR neurography, has become increasingly important in the work-up of entrapment neuropathies involving the pelvic and hip nerves of the lumbosacral plexus. The major sensory and motor peripheral nerves of the pelvis and hip include the sciatic nerve, superior and inferior gluteal nerves, femoral nerve, lateral femoral cutaneous nerve, obturator nerve, and pudendal nerve. Familiarity with the anatomy and imaging appearance of normal and pathologic nerves in combination with clinical presentation is crucial in the diagnosis of entrapment neuropathies.
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Affiliation(s)
- Lawrence Lo
- Department of Radiology, University of Pennsylvania, Penn Medicine at University City, Philadelphia, Pennsylvania
| | - Alejandra Duarte
- Division of Musculoskeletal Radiology, Department of Radiology, Fundación Santa Fe de Bogotá, Bogotá, Colombia
| | - Jenny T Bencardino
- Division of Musculoskeletal Radiology, Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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13
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Abstract
Cycle use has grown rapidly over the last few years in the UK. British Cycling membership has increased threefold since the 2012 Olympic and Paralympic Games, and this is likely to rise in the wake of the Coronavirus pandemic. As urologists, day-to-day encounters with cyclists are commonplace, who may present with acute traumatic injuries or chronic overuse injuries. The aim of this literature review was to evaluate the effect of cycling on conditions presenting to the urology clinic, in particular those of raised prostate-specific antigen (PSA), haematuria and soft-tissue lesions (‘cyclist nodules’). Furthermore, the review aimed to summarize the relationship between cycling and pudendal nerve entrapment (PNE) syndromes. A PubMed search of the literature on cycling and genitourinary disorders was performed. The literature suggests no significant change in PSA levels after a bout of cycling. Age appears to have no effect on the change in PSA experienced following a bout of cycling, in particular when comparing those <50 years of age to those >50 years of age. Haematuria appears to be rare with cycling but has been described, even with stationary bike riding. It is imperative to exclude coexisting urinary-tract pathological conditions, and cycling-induced haematuria should always be considered a diagnosis of exclusion. Perineal nodular induration (‘cyclist nodules’) is a rare condition, related to pressure and repetitive micro-trauma between the perineum and saddle. Pudendal Nerve Entrapment (PNE) represents the most common bicycling-associated urogenital complaint. Numbness in the perineum, penis, scrotum or buttocks—‘genital numbness’—is the most common and most recognized symptom of pudendal compression. Despite several studies demonstrating a link between elite cyclists and erectile dysfunction, for the average cyclist riding may actually have a protective effect on sexual function.
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Affiliation(s)
- J Peacock
- Cheltenham General Hospital, Gloucestershire Hospitals NHS Trust, UK
| | - J Cobley
- Cheltenham General Hospital, Gloucestershire Hospitals NHS Trust, UK
| | - B Patel
- Cheltenham General Hospital, Gloucestershire Hospitals NHS Trust, UK
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14
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Sconfienza LM, Adriaensen M, Albano D, Alcala-Galiano A, Allen G, Aparisi Gómez MP, Aringhieri G, Bazzocchi A, Beggs I, Chianca V, Corazza A, Dalili D, De Dea M, Del Cura JL, Di Pietto F, Drakonaki E, Facal de Castro F, Filippiadis D, Gitto S, Grainger AJ, Greenwood S, Gupta H, Ivanoski S, Khanna M, Klauser A, Mansour R, Martin S, Mascarenhas V, Mauri G, McCarthy C, McKean D, McNally E, Melaki K, Messina C, Miron Mombiela R, Moutinho R, Olchowy C, Orlandi D, Prada González R, Prakash M, Posadzy M, Rutkauskas S, Snoj Ž, Tagliafico AS, Talaska A, Tomas X, Vasilevska Nikodinovska V, Vucetic J, Wilson D, Zaottini F, Zappia M, Isaac A. 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. Eur Radiol 2022; 32:1456-1464. [PMID: 34581843 PMCID: PMC8831230 DOI: 10.1007/s00330-021-08283-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Revised: 08/01/2021] [Accepted: 08/17/2021] [Indexed: 12/23/2022]
Abstract
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.
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Affiliation(s)
- Luca Maria Sconfienza
- IRCCS Istituto Ortopedico Galeazzi, Milan, Italy.
- Dipartimento Di Scienze Biomediche Per La Salute, Università Degli Studi Di Milano, Via Riccardo Galeazzi 4, 20161, Milan, Italy.
| | - Miraude Adriaensen
- Department of Medical Imaging, Zuyderland Medical Center, Sittard-Geleen, Heerlen, Brunssum, Kerkrade, the Netherlands
| | - Domenico Albano
- IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
- Sezione Di Scienze Radiologiche, Dipartimento Di Biomedicina, Neuroscienze E Diagnostica Avanzata, Università Degli Studi Di Palermo, Palermo, Italy
| | | | - Georgina Allen
- St Luke's Radiology Oxford Ltd, Oxford, UK
- University of Oxford, Oxford, UK
| | - Maria Pilar Aparisi Gómez
- Department of Radiology, Auckland City Hospital, Auckland, New Zealand
- Department of Radiology, Hospital Vithas Nueve de Octubre, Valencia, Spain
| | - Giacomo Aringhieri
- Diagnostic and Interventional Radiology, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Alberto Bazzocchi
- Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | | | - Vito Chianca
- Ospedale Evangelico Betania, Napoli, Italy
- Clinica Di Radiologia EOC IIMSI, Lugano, Switzerland
| | | | - Danoob Dalili
- South West London Elective Orthopaedic Centre (SWLEOC), Epsom & St Helier University Hospitals NHS Trust, London, UK
| | | | | | - Francesco Di Pietto
- Dipartimento Di Diagnostica Per Immagini, Pineta Grande Hospital, Castel Volturno, Italy
| | | | | | - Dimitrios Filippiadis
- 2nd Department of Radiology, University General Hospital "ATTIKON" Medical School, National and Kapodistrian University of Athens, Haidari/Athens, Greece
| | - Salvatore Gitto
- Dipartimento Di Scienze Biomediche Per La Salute, Università Degli Studi Di Milano, Milan, Italy
| | | | | | | | - Slavcho Ivanoski
- Department of Radiology, Special Hospital for Orthopedic Surgery and Traumatology St. Erazmo, Ohrid, North Macedonia
- Ss. Cyril and Methodius University in Skopje, Skopje, North Macedonia
| | | | - Andrea Klauser
- Department of Radiology, Medical University Innsbruck, Innsbruck, Austria
| | - Ramy Mansour
- Oxford Musculoskeletal Radiology, Oxford University Hospitals, Oxford, UK
| | | | - Vasco Mascarenhas
- Hospital da Luz, Musculoskeletal Imaging Unit, Lisbon, Portugal
- AIRC, Advanced imaging research consortium, Lisbon, Portugal
| | - Giovanni Mauri
- Division of Interventional Radiology, Istituto Europeo Di Oncologia, Milan, Italy
| | | | - David McKean
- Buckinghamshire Healthcare NHS Trust, Aylesbury, UK
| | | | - Kalliopi Melaki
- Department of Radiology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | | | | | - Ricardo Moutinho
- Hospital da Luz, Musculoskeletal Imaging Unit, Lisbon, Portugal
- Hospital de Loulé, Loulé, Portugal
| | - Cyprian Olchowy
- Department of Oral Surgery, Wroclaw Medical University, Wroclaw, Poland
| | - Davide Orlandi
- Department of Radiology, Ospedale Evangelico Internazionale, Genoa, Italy
| | | | - Mahesh Prakash
- Post Graduate Institute of Medical Education & Research (PGIMER), Chandigarh, India
| | | | - Saulius Rutkauskas
- Department of Radiology, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Žiga Snoj
- Institute of Radiology, University Medical Centre Ljubljana, Zaloska 7, 1000, Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Alberto Stefano Tagliafico
- Department of Health Sciences, University of Genova, Genoa, Italy
- IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | | | - Xavier Tomas
- Radiology Dpt. MSK Unit. Hospital Clinic (CDIC), University of Barcelona (UB), Barcelona, Spain
| | - Violeta Vasilevska Nikodinovska
- Clinical Center "Mother Theresa", University Institute of Radiology, Skopje, North Macedonia
- Faculty of Medicine, Ss. Cyril and Methodius University in Skopje, Skopje, North Macedonia
| | - Jelena Vucetic
- Radiology Department, Hospital ICOT Ciudad de Telde, Las Palmas, Spain
| | | | | | - Marcello Zappia
- Department of Medicine and Health Sciences, University of Molise, Campobasso, Italy
- Varelli Institute, Naples, Italy
- Guy's and St Thomas' Hospitals, London, UK
| | - Amanda Isaac
- South West London Elective Orthopaedic Centre (SWLEOC), Epsom & St Helier University Hospitals NHS Trust, London, UK
- Guy's and St Thomas' Hospitals, London, UK
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15
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Cai ZJ, Salem AE, Wagner-Bartak NA, Elsayes KM, Negm AS, Rezvani M, Menias CO, Shaaban AM. Sciatic foramen anatomy and common pathologies: a pictorial review. Abdom Radiol (NY) 2022; 47:378-398. [PMID: 34664097 DOI: 10.1007/s00261-021-03265-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 08/23/2021] [Accepted: 08/25/2021] [Indexed: 11/25/2022]
Abstract
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.
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Affiliation(s)
- Zhuoxuan J Cai
- Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, 1400 Pressler Street, Houston, TX, 77030, USA
| | - Ahmed Ebada Salem
- Department of Diagnostic Radiology, University of Utah, Salt Lake City, UT, USA
- Department of Diagnostic Radiology, Mayo Clinic, Phoenix, AZ, USA
| | - Nicolaus A Wagner-Bartak
- Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, 1400 Pressler Street, Houston, TX, 77030, USA
| | - Khaled M Elsayes
- Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, 1400 Pressler Street, Houston, TX, 77030, USA.
| | - Ahmed S Negm
- Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, 1400 Pressler Street, Houston, TX, 77030, USA
| | - Maryam Rezvani
- Department of Diagnostic Radiology, University of Utah, Salt Lake City, UT, USA
| | - Christine O Menias
- Department of Radiodiagnosis and Intervention, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Akram M Shaaban
- Department of Diagnostic Radiology, University of Utah, Salt Lake City, UT, USA
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16
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Uyanık H, Örmeci B, Taşdelen N, Keleş E, Erdoğru T, Öge A. Dynamic somatosensory evoked potential and magnetic resonance imaging in pudendal neuropathy: A comparative study with respect to the clinical diagnostic criteria. NEUROL SCI NEUROPHYS 2022. [DOI: 10.4103/nsn.nsn_239_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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17
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Deep Gluteal Pain in Orthopaedics: A Challenging Diagnosis. J Am Acad Orthop Surg 2021; 29:e1282-e1290. [PMID: 34874333 DOI: 10.5435/jaaos-d-21-00707] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2021] [Accepted: 09/02/2021] [Indexed: 02/01/2023] Open
Abstract
Identifying the specific source of gluteal pain can elude the most seasoned orthopaedic diagnosticians. Patients will often present with a protracted course of symptoms, and failure to successfully identify and treat the underlying etiology leads to frustration for both patient and clinician. Pain deep in the buttocks can arise from compression, inflammation, or injury of one or more of the structures in this anatomically dense area. Although sacroiliitis, hip arthritis, and trochanteric bursitis may also masquerade as gluteal pain, sciatic nerve irritation in its various presentations causes a substantial percentage of cases. Deep gluteal syndrome, hamstring syndrome, and ischiofemoral impingement can have overlapping presentations but can be differentiated by clinical examination and judiciously placed diagnostic corticosteroid injections. Although nonsurgical management, including physical therapy, relative rest, and injections represent the mainstay of treatment, open and endoscopic surgical approaches have yielded encouraging success rates in refractory cases.
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18
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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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19
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Li Y, Liu H, Nichols C, Mason DC. Manual Therapy Treatment for Penile Pain- A Clinical Case Report with 6-Month Follow-up. J Man Manip Ther 2021; 30:124-131. [PMID: 34657580 DOI: 10.1080/10669817.2021.1985693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
BACKGROUND Male genital pain, which is neither related to genitourinary nor other obvious pathology, is an uncommon symptom in male patients and not frequently treated using manual therapy. The purpose of this case study is to describe a clinical reasoning process in combination with anatomy-based differential diagnosis and manual treatment for genital pain. CASE DESCRIPTION A male patient with a 3-week acute onset of genital pain was hospitalized and referred for evaluation and treatment after unsuccessful treatment with medication and acupuncture. Clinical examination was performed indicating a possible nerve entrapment followed by interventions of ligamentous articular strain, high-velocity low-amplitude (HVLA) manipulation, and strain- and counterstain, coupled with soft tissue stretching to lumbar and inguinal areas to address a possible lumbar referral potentially from L1 and/or ilioinguinal nerve entrapment. OUTCOMES After 4 consecutive days of manipulative treatment, pain decreased from 9/10 to 0/10 and the Barthel Index improved from 50 to 95. A 6-month follow-up revealed complete resolution of symptoms with no recurrence. DISCUSSION This case illustrates that a detailed history and examination along with a reasoned diagnostic process to determine an appropriate intervention strategy may improve patient care using manual therapy techniques. CONCLUSION By utilizing a deductive reasoning process related to the penile area, clinicians may better apply manual therapy techniques for successful treatment.
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Affiliation(s)
- Yingzhi Li
- Department of Acupuncture and Manual Therapy, Yunnan University of Traditional Chinese Medicine, Kunming, China
| | - Howe Liu
- Department of Physical Therapy, University of North Texas Health Science Center, Fort Worth, TX, USA
| | - Charles Nichols
- Department of Physical Therapy, University of North Texas Health Science Center, Fort Worth, TX, USA
| | - David C Mason
- Department of Family Medicine and Osteopathic Manipulative Medicine, University of North Texas Health Science Center-Texas College of Osteopathic Medicine, Fort Worth, TX, USA
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20
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Aoun F, Alkassis M, Tayeh GA, Chebel JA, Semaan A, Sarkis J, Mansour R, Mjaess G, Albisinni S, Absil F, Bollens R, Roumeguère T. Sexual dysfunction due to pudendal neuralgia: a systematic review. Transl Androl Urol 2021; 10:2500-2511. [PMID: 34295736 PMCID: PMC8261452 DOI: 10.21037/tau-21-13] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 01/26/2021] [Indexed: 01/16/2023] Open
Abstract
Background The pudendal nerve is considered as the main nerve of sexuality. Pudendal neuralgia is an underdiagnosed disease in clinical practice. The aim of this systematic review is to highlight the role of pudendal neuralgia on sexual dysfunction in both sexes. Methods A PubMed search was performed using the following keywords: “Pudendal” AND “Sexual dysfunction” or “Erectile dysfunction” or “Ejaculation” or “Persistent sexual arousal” or “Dyspareunia” or “Vulvodynia”. The search involved patients having sexual dysfunction due to pudendal neuralgia. Treatment received was also reported. Results Five case series, seven cohort studies, two pilot studies, and three randomized clinical trials were included in this systematic review. Pudendal nerve and/or artery entrapment, or pudendal neuralgia, is a reversible cause of multiple sexual dysfunctions. Interventions such as anesthetic injections, neurolysis, and decompression are reported as potential treatment modalities. There are no studies describing the role of pudendal canal syndrome in the pathophysiology or treatment of delayed ejaculation or penile shortening. Discussion Pudendal neuralgia is an underestimated yet important cause of persistent genital arousal, erectile dysfunction (ED), premature ejaculation (PE), ejaculation pain, and vulvodynia. Physicians should be aware of this entity and examine the pudendal canal in such patients before concluding an idiopathic cause of sexual dysfunction.
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Affiliation(s)
- Fouad Aoun
- Urology Department, Hôtel Dieu de France, Université Saint Joseph, Beirut, Lebanon.,Urology Department, Institut Jules Bordet, Université Libre de Bruxelles, Brussels, Belgium
| | - Marwan Alkassis
- Urology Department, Hôtel Dieu de France, Université Saint Joseph, Beirut, Lebanon
| | - Georges Abi Tayeh
- Urology Department, Hôtel Dieu de France, Université Saint Joseph, Beirut, Lebanon
| | - Josselin Abi Chebel
- Urology Department, Hôtel Dieu de France, Université Saint Joseph, Beirut, Lebanon
| | - Albert Semaan
- Urology Department, Hôtel Dieu de France, Université Saint Joseph, Beirut, Lebanon
| | - Julien Sarkis
- Urology Department, Hôtel Dieu de France, Université Saint Joseph, Beirut, Lebanon
| | - Raymond Mansour
- Urology Department, Hôtel Dieu de France, Université Saint Joseph, Beirut, Lebanon
| | - Georges Mjaess
- Urology Department, Hôtel Dieu de France, Université Saint Joseph, Beirut, Lebanon.,Urology Department, Cliniques Universitaires de Bruxelles, Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Simone Albisinni
- Urology Department, Cliniques Universitaires de Bruxelles, Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Fabienne Absil
- Urology department, Centre Hospitalier EpiCURA, Site de Ath, Ath, Belgium
| | - Renaud Bollens
- Urology department, Centre Hospitalier de Wallonie Picarde, Tournai, Belgium
| | - Thierry Roumeguère
- Urology Department, Institut Jules Bordet, Université Libre de Bruxelles, Brussels, Belgium.,Urology Department, Cliniques Universitaires de Bruxelles, Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
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21
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Soucy B, Luong DH, Michaud J, Boudier-Revéret M, Sobczak S. Accuracy of Ultrasound-Guided Pudendal Nerve Block in the Ischial Spine and Alcock's Canal Levels: A Cadaveric Study. PAIN MEDICINE 2021; 21:2692-2698. [PMID: 32451530 DOI: 10.1093/pm/pnaa136] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
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.
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Affiliation(s)
- Béatrice Soucy
- Department of Physical Medicine and Rehabilitation, Université de Montréal, Montreal, Canada
| | - Dien Hung Luong
- Department of Physical Medicine and Rehabilitation, Université de Montréal, Montreal, Canada
| | - Johan Michaud
- Department of Physical Medicine and Rehabilitation, Université de Montréal, Montreal, Canada
| | - Mathieu Boudier-Revéret
- Department of Physical Medicine and Rehabilitation, Université de Montréal, Montreal, Canada
| | - Stéphane Sobczak
- Department of Anatomy.,Research Unit of Clinical and Functional Anatomy, Université du Québec à Trois-Rivières, Trois-Rivières, Canada
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Neurolysis of the Dorsal Nerve to the Penis to Restore Function After Trauma. Ann Plast Surg 2021; 84:307-311. [PMID: 31904648 DOI: 10.1097/sap.0000000000002144] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Loss of penile sensation or development of a painful penis and erectile dysfunction can occur after injury to the dorsal branch of the pudendal nerve. Although recovery of genital sensibility has been discussed frequently in transmen, this subject has been reported rarely in cismen. The purpose of this report is to review our experience with recovery of sensation in men after decompression of the dorsal branch of the pudendal nerve after trauma. METHODS A retrospective chart review of men who have had decompression of the dorsal branch of the pudendal nerve was carried out from 2014 to 2018. Patients were included in the cohort if they had a loss of penile sensation or the development of a painful penis after trauma. Primary outcomes measured were the change in penile symptoms, including erection, ejaculation, ejaculatory pain, erogenous sensation, numbness, and penile pain. RESULTS For the 7 men included in this study, the mean follow-up time was 57 weeks (range, 28-85 weeks). Bilateral surgery was done in 71% (5/7). Of the 6 patients with loss of penile sensation, complete recovery of erogenous sensibility occurred in 5 (83%) patients, with partial relief in 1 (17%) patient. Of the 3 men who had erectile dysfunction, normal erections were restored in 2 (67%) patients. Of the 2 patients unable to ejaculate, 1 (50%) patient regained ejaculatory function. Of the 4 patients with ejaculatory pain, complete relief of pain occurred in 2 (50%) patients, with partial relief in 2 (50%) patients. Of the 6 patients with penile pain in the absence of ejaculation, complete relief of pain occurred in 3 (50%) patients, with partial relief in 3 (50%) patients. CONCLUSION Neurolysis of the dorsal nerve to the penis at the inferior pubic ramus canal can be successful in relieving pain, and restoring sensation and erectile function in men who sustained an injury along the inferior pubic ramus.
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Pudendal Nerve Identified on Sectioned Images of Female Cadaveric Pelvis. Urology 2020; 142:76-80. [DOI: 10.1016/j.urology.2020.05.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 05/02/2020] [Accepted: 05/04/2020] [Indexed: 11/18/2022]
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Afonso Ramos S, Guimarães T, Bollens R. Urethral leak: an unusual symptom of pudendal nerve entrapment. Cent European J Urol 2020; 73:46-48. [PMID: 32395323 PMCID: PMC7203779 DOI: 10.5173/ceju.2020.0024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 02/10/2020] [Accepted: 02/10/2020] [Indexed: 11/22/2022] Open
Abstract
Pudendal nerve (PN) entrapment is one of the most misunderstood and underdiagnosed medical conditions. It is recognized as a cause of chronic pelvic pain syndrome. However, due to the pudendal nerve’s mixed composition and complex anatomy, the presenting symptoms are varied and go beyond pain, depending on the entrapment’s nature, location and duration. We report a unique case of a young patient presenting with a urethral leak refractory to antibiotics. Patient evaluation highlighted findings suspicious of pudendal nerve entrapment. The patient was submitted to a laparoscopic transperitoneal PN neurolysis, resulting in major symptoms improvement.
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Affiliation(s)
- Sónia Afonso Ramos
- Hospital Prof. Doutor Fernando Fonseca, Department of Urology, Amadora, Portugal
| | - Thiago Guimarães
- Centro Hospitalar Lisboa Central, Department of Urology, Lisboa, Portugal
| | - Renaud Bollens
- Centre Hospitalier Wallonie Picarde, Tournai, Belgium.,Centre Hospitalier Hornu / Frameries, Hornu, Belgium
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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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Klifto KM, Dellon AL. Persistent Genital Arousal Disorder: Review of Pertinent Peripheral Nerves. Sex Med Rev 2019; 8:265-273. [PMID: 31704111 DOI: 10.1016/j.sxmr.2019.10.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Revised: 10/01/2019] [Accepted: 10/11/2019] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Persistent genital arousal disorder (PGAD) is a condition that is still poorly understood. Etiologies reported for PGAD are vascular, neurological, pharmacological, and psychological. Determining the neurophysiological etiology of PGAD began with developing an understanding of the underlying biomechanics of the pudendal nerve and the female sexual response. AIM To summarize the anatomy, physiology, etiologies, diagnostics, and treatments of the pertinent peripheral nerves involved in the pathology of PGAD. METHODS We performed a PubMed, Cochrane, Embase, Web of Science, and Google Scholar search for English-language articles in peer-reviewed journals with no predefined time period for inclusion. Terms included "humans"[All Fields] AND "persistent"[All Fields] AND/OR ("genitalia"[All Fields] OR "genital"[All Fields]) AND/OR "arousal"[All Fields] AND/OR ("disease"[All Fields] OR "disorder"[All Fields]) AND/OR "nerve"[All Fields]. The main outcomes of the papers were reviewed. MAIN OUTCOME MEASURE The main outcome measures were the anatomy and physiology, etiologies, history and physical examination, diagnostic imaging, and current evidence for the treatment of PGAD related to the peripheral nervous system. RESULTS Most of the literature for PGAD originates from case studies. The diagnosis of PGAD itself is still a debated topic of discussion. More recent data published indicate that this disease affects males, as well. CONCLUSION Nerve entrapment may be a source of continuous arousal. Associated PGAD symptoms would depend on the segment of the nerve involved. Unwelcomed or unwanted arousal has been observed as the most common detrimental symptom. Pelvic 3-tesla magnetic resonance imaging is recommended in all patients with suspected nerve entrapment. Lumbosacral 3-tesla magnetic resonance imaging is recommended if a Tarlov cyst or a herniated intervertebral disc is suspected. If the peripheral nerve is the source of the pathology, surgical intervention may be curative. A multidisciplinary team approach consisting of a medical provider, pelvic floor physical therapist, and sex therapist has demonstrated benefits. There are currently no Food and Drug Administration-approved evidenced-based treatments for PGAD. Klifto KM, Dellon AL. Persistent Genital Arousal Disorder: Review of Pertinent Peripheral Nerves. Sex Med Rev 2020;8:265-273.
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Affiliation(s)
- Kevin M Klifto
- Department of Plastic and Reconstructive Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - A Lee Dellon
- Department of Plastic and Reconstructive Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, MD.
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Luther RD, Castellanos ME. Successful Treatment of Penile Numbness and Erectile Dysfunction Resulting From Pudendal Nerve Entrapment. Urology 2019; 134:228-231. [PMID: 31560912 DOI: 10.1016/j.urology.2019.09.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Revised: 09/05/2019] [Accepted: 09/14/2019] [Indexed: 10/26/2022]
Abstract
Pudendal nerve decompression surgery has not been studied or reported for the treatment of penile numbness in the absence of pain. Herein, we report a case of a male patient with chronic numbness of the penis and erectile dysfunction in the absence of pelvic pain who was found to have pudendal nerve entrapment. This patient was treated with surgical decompression of the pudendal nerves that resulted in the return of genital sensation and erections. Thus, we propose that pudendal nerve entrapment may be considered as a cause of penile numbness and that pudendal nerve decompression surgery in these patients may be effective.
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Affiliation(s)
- Ross D Luther
- Creighton University School of Medicine, Phoenix Regional Campus, Phoenix, AZ
| | - Mario E Castellanos
- Creighton University School of Medicine, Phoenix Regional Campus, Phoenix, AZ.
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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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Klifto K, Dellon AL. Persistent genital arousal disorder: Treatment by neurolysis of dorsal branch of pudendal nerve. Microsurgery 2019; 40:160-166. [PMID: 31025770 DOI: 10.1002/micr.30464] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2018] [Revised: 03/29/2019] [Accepted: 04/16/2019] [Indexed: 01/13/2023]
Abstract
BACKGROUND Persistent genital arousal disorder (PGAD) is a woman's perception that she is in a state of sexual arousal, without the ability of arousal to be satisfied by orgasm. It is the hypothesis of this study that PGAD results from a minimal degree of nerve compression of the dorsal branch of the pudendal nerve. If this is true, PGAD could be treated by neurolysis of the dorsal branch of the pudendal nerve. METHODS A retrospective chart review from 2010 through 2018, of those women having neurolysis of the dorsal branch of the pudendal nerve for PGAD. The main outcome measures were the pre-operative and post-operative changes in clitoral symptoms (arousal, numbness, pain). RESULTS Eight women included in this study were followed more than 26 weeks since surgery (mean = 65, range = 26-144 weeks). Seven of these women had the surgery bilaterally, and each of these had an excellent result, meaning elimination of the arousal symptoms, and the ability to resume normal sexual intercourse. The patient with unilateral decompression of the dorsal branch of the pudendal nerve was the only patient who had some, versus complete improvement in arousal symptoms. Of the seven women that had pain, six had complete relief and one had partial relief. No major surgical complications were observed. CONCLUSION The relief of arousal symptoms by neurolysis of the dorsal nerve to the clitoris supports the hypothesis that PGAD is due to a minimal degree of compression of the dorsal branch of the pudendal nerve.
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Affiliation(s)
- Kevin Klifto
- Department of Plastic Surgery, Johns Hopkins University, Baltimore, Maryland
| | - A Lee Dellon
- Department of Plastic Surgery, Johns Hopkins University, Baltimore, Maryland.,Department of Neurosurgery, Johns Hopkins University, Baltimore, Maryland
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Pukall CF, Jackowich R, Mooney K, Chamberlain SM. Genital Sensations in Persistent Genital Arousal Disorder: A Case for an Overarching Nosology of Genitopelvic Dysesthesias? Sex Med Rev 2019; 7:2-12. [DOI: 10.1016/j.sxmr.2018.08.001] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Revised: 07/24/2018] [Accepted: 08/05/2018] [Indexed: 12/14/2022]
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Abstract
Understanding the etiology of and evolving research on intra- and extra-articular hip complaints requires comprehensive diagnosis and management of the spectrum of posterior hip diseases. Interest in posterior hip disorders has increased in recent years as new studies and theories have emerged regarding the disease process. Although most of the differential diagnoses around the posterior hip have traditionally been considered uncommon, recent reports suggest that these complaints have instead been commonly overlooked. Failure to identify the cause of posterior hip pain in a timely manner can increase pain perception, deteriorate the patient's hope, and consequently affect quality of life. Posterior hip pain could be differentiated as intrapelvic and extrapelvic, and differential diagnosis is made based on a comprehensive history, physical examination, and imaging studies. Plain radiography, CT, MRI, 3T MRI, and imaging-guided injection tests are usually necessary for accurate diagnosis. Surgical intervention, whether endoscopic or open, is required for patients with long-standing symptoms for whom nonsurgical treatment has been unsuccessful and who have experienced temporary relief of their symptoms after injection. Orthopedic surgeons are uniquely trained in understanding the anatomy, biomechanics, clinical evaluation and treatment of all five layers of the hip.
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Yuan X, Bevelaqua AC. Buttock Pain in the Athlete: the Role of Pelvic Floor Dysfunction. CURRENT PHYSICAL MEDICINE AND REHABILITATION REPORTS 2018. [DOI: 10.1007/s40141-018-0188-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Dessouky R, Xi Y, Scott KM, Khaleel M, Gill K, Jones S, Khalifa DN, Tantawy HI, Aidaros MA, Chhabra A. Magnetic Resonance Neurography in Chronic Lumbosacral and Pelvic Pain: Diagnostic and Management Impact-Institutional Audit. World Neurosurg 2018; 114:e77-e113. [PMID: 29581014 DOI: 10.1016/j.wneu.2018.02.072] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2018] [Revised: 02/10/2018] [Accepted: 02/12/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND/OBJECTIVE Low back and pelvic pain are among the most prevalent conditions worldwide, with major social and economic costs. The aim of this study was to evaluate the role of magnetic resonance neurography (MRN) of lumbosacral plexus in the management and outcomes of these patients with chronic pain. METHODS Consecutive patients with chronic lumbosacral and pelvic pain referred for MRN over a year were included. Preimaging and postimaging clinical diagnosis and treatment, pain levels, and location were recorded. Pain-free survival was compared between treatments using a Cox proportional hazards model. RESULTS A total of 202 patients with mean age 53.7 ± 14.8 years and a male/female ratio of 1:1.53 were included. Of these patients, 115 presented with radiculopathy (57%), 56 with pelvic pain (28%), and 31 with groin pain (15%). Mean initial pain level was 6.9 ± 1.9. Mean symptom duration was 4.21 ± 5.86 years. Of these patients, 143 (71%) had a change in management because of MRN. After MRN, reduction in pain levels was observed in 21 of 32 patients receiving conservative treatment (66%), 42 of 67 receiving injections (63%), and 27 of 33 receiving surgery (82%). Follow-ups were available in 131 patients. Median pain-free survival was 12 months. Patients treated with surgery had significantly lower pain recurrence than patients receiving other treatments in the same time frame (hazard ratio, 3.6; 95% confidence interval, 1.4-9.2; P = 0.0061). CONCLUSIONS MRN use in chronic lumbosacral and pelvic pain led to a meaningful change in diagnosis and treatment. After MRN, conservative treatment and injections provided pain relief; however, patients benefited more from surgery than from any other treatment.
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Affiliation(s)
- Riham Dessouky
- Department of Radiology, University of Texas Southwestern Medical Center, Dallas, Texas, USA; Department of Radiology, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Yin Xi
- Department of Radiology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Kelly M Scott
- Department of Physical Medicine and Rehabilitation, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Mohammed Khaleel
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Kevin Gill
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Stephanie Jones
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Dalia N Khalifa
- Department of Radiology, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Hazim I Tantawy
- Department of Radiology, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Magdy A Aidaros
- Department of Neurology, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Avneesh Chhabra
- Department of Radiology, University of Texas Southwestern Medical Center, Dallas, Texas, USA.
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Tobar Roa V, Gómez M, González A, Zableh A. Neuropatía del pudendo como causa de dolor pélvico. UROLOGÍA COLOMBIANA 2018. [DOI: 10.1016/j.uroco.2017.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
ResumenEl 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.
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Affiliation(s)
- Verónica Tobar Roa
- Universidad Autónoma de Bucaramanga; Uróloga Pontificia Universidad Javeriana; Máster Universitario de Investigación Clínica en Donación y Trasplante de Órganos, Tejidos y Células, Universidad de Barcelona; Uróloga, Centro Urológico Foscal, Floridablanca, Santander, Colombia
| | - María Gómez
- Universidad Industrial de Santander; Anestesióloga, Universidad Militar Nueva Granada; Fellow Anestesia Regional guiada por Ultrasonido programa CLASA-WFSA-SBA; Anestesióloga Sociedad Especializada de Anestesiología SEA S.A., Clínica Carlos Ardila Lulle, Floridablanca, Santander, Colombia
| | - Ana González
- Universidad Autónoma de Bucaramanga; Residente de Segundo año de Urología, Universidad Autónoma de Bucaramanga, Floridablanca, Santander, Colombia
| | - Ana Zableh
- Interna, Pontificia Universidad Javeriana, Bogotá, Colombia
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Muniz Neto FJ, Kihara Filho EN, Miranda FC, Rosemberg LA, Santos DCB, Taneja AK. Demystifying MR Neurography of the Lumbosacral Plexus: From Protocols to Pathologies. BIOMED RESEARCH INTERNATIONAL 2018; 2018:9608947. [PMID: 29662907 PMCID: PMC5832061 DOI: 10.1155/2018/9608947] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Accepted: 11/29/2017] [Indexed: 12/14/2022]
Abstract
Magnetic resonance neurography is a high-resolution imaging technique that allows evaluating different neurological pathologies in correlation to clinical and the electrophysiological data. The aim of this article is to present a review on the anatomy of the lumbosacral plexus nerves, along with imaging protocols, interpretation pitfalls, and most common pathologies that should be recognized by the radiologist: traumatic, iatrogenic, entrapment, tumoral, infectious, and inflammatory conditions. An extensive series of clinical and imaging cases is presented to illustrate key-points throughout the article.
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Affiliation(s)
- Francisco J. Muniz Neto
- Musculoskeletal Radiology Division, Imaging Department, Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
| | - Eduardo N. Kihara Filho
- Musculoskeletal Radiology Division, Imaging Department, Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
| | - Frederico C. Miranda
- Musculoskeletal Radiology Division, Imaging Department, Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
| | - Laercio A. Rosemberg
- Musculoskeletal Radiology Division, Imaging Department, Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
| | - Durval C. B. Santos
- Musculoskeletal Radiology Division, Imaging Department, Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
| | - Atul K. Taneja
- Musculoskeletal Radiology Division, Imaging Department, Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
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Martin RL, Schröder RG, Gomez-Hoyos J, Khoury AN, Palmer IJ, McGovern RP, Martin HD. Accuracy of 3 Clinical Tests to Diagnose Proximal Hamstrings Tears With and Without Sciatic Nerve Involvement in Patients With Posterior Hip Pain. Arthroscopy 2018; 34:114-121. [PMID: 29203381 DOI: 10.1016/j.arthro.2017.06.048] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Revised: 06/24/2017] [Accepted: 06/27/2017] [Indexed: 02/02/2023]
Abstract
PURPOSE To determine the diagnostic accuracy of the active hamstring test at 30° (A-30) and 90° (A-90) of knee flexion, the long stride heel strike (LSHS) test, and combination of the 3 tests for individuals with hamstring tendon tears, with and without sciatic nerve involvement. METHODS A retrospective review of 564 consecutive clinical records identified 42 subjects with a mean age of 50.31 ± 15 years who underwent a standard physical examination prior to magnetic resonance imaging (MRI) evaluation and diagnostic injection for posterior hip. The physical examination included the A-30, A-90, and LSHS tests. Sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, and diagnostic odds ratio were calculated to determine the diagnostic accuracy of these 3 tests. RESULTS Forty-two subjects (female = 32 and male = 10) with a mean age of 50.31 years (range 15-77, ± SD 14.52) met the inclusion criteria and were included in the review. Based on MRI and/or injection, 64.28% (27/42) of subjects were diagnosed with hamstring tear. Fourteen (51.85%) presented with sciatic nerve involvement. The sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, and diagnostic odds ratio for each test were as follows: A-30 knee flexion: 0.73, 0.97, 23.43, 0.28, and 84.73; A-90 knee flexion: 0.62, 0.97, 20.00, 0.39, and 51.67; LSHS: 0.55, 0.73, 2.08, 0.61, and 3.44. The most accurate findings were obtained when the results of the A-30 and A-90 were combined, with sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, and diagnostic odds ratio of 0.84, 0.97, 26.86, 0.17, and 161.89, respectively. CONCLUSION The combination of the active hamstring A-30 and A-90 tests proved to be a highly accurate and valuable tool to diagnose proximal hamstring tendons tears with or without sciatic nerve involvement in subjects presenting with posterior hip pain. LEVEL OF EVIDENCE Level III, diagnostic study.
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Affiliation(s)
- RobRoy L Martin
- Department of Physical Therapy, Duquesne University, Pittsburg, Pennsylvania, U.S.A.; UPMC Center for Sports Medicine, Pittsburgh, Pennsylvania, U.S.A
| | | | - Juan Gomez-Hoyos
- Orthopedic Unit, Clínica Las Américas, Medellín, Colombia; GRINMADE Research Group, Universidad de Antioquia, Medellín, Colombia
| | - Anthony N Khoury
- Hip Preservation Center, Baylor Scott&White Health System, Dallas, Texas, U.S.A
| | - Ian James Palmer
- Hip Preservation Center, Baylor Scott&White Health System, Dallas, Texas, U.S.A
| | - Ryan P McGovern
- Rangos School of Health Sciences, Duquesne University, Pittsburgh, Pennsylvania, U.S.A
| | - Hal David Martin
- Hip Preservation Center, Baylor Scott&White Health System, Dallas, Texas, U.S.A..
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Magnetic Resonance Imaging of Hip Neuropathies: Beyond the Sciatica: A Practical Approach. CURRENT RADIOLOGY REPORTS 2017. [DOI: 10.1007/s40134-017-0230-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Wadhwa V, Hamid AS, Kumar Y, Scott KM, Chhabra A. Pudendal nerve and branch neuropathy: magnetic resonance neurography evaluation. Acta Radiol 2017; 58:726-733. [PMID: 27664277 DOI: 10.1177/0284185116668213] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Pudendal neuralgia is being increasingly recognized as a cause of chronic pelvic pain, which may be related to nerve injury or entrapment. Due to its complex anatomy and branching patterns, the pudendal nerve abnormalities are challenging to illustrate. High resolution 3 T magnetic resonance neurography is a promising technique for the evaluation of peripheral neuropathies. In this article, the authors discuss the normal pudendal nerve anatomy and its variations, technical considerations of pudendal nerve imaging, and highlight the normal and abnormal appearances of the pudendal nerve and its branches with illustrative case examples.
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Affiliation(s)
- Vibhor Wadhwa
- Department of Radiology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Aws S Hamid
- Department of Radiology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Yogesh Kumar
- Department of Radiology, Yale New Haven Health System at Bridgeport Hospital, Bridgeport, Connecticut, USA
| | - Kelly M Scott
- Department of Physical Medicine & Rehabilitation, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Avneesh Chhabra
- Department of Radiology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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Freeberg MJ, Stone MA, Triolo RJ, Tyler DJ. The design of and chronic tissue response to a composite nerve electrode with patterned stiffness. J Neural Eng 2017; 14:036022. [PMID: 28287078 DOI: 10.1088/1741-2552/aa6632] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVE As neural interfaces demonstrate success in chronic applications, a novel class of reshaping electrodes with patterned regions of stiffness will enable application to a widening range of anatomical locations. Patterning stiff regions and flexible regions of the electrode enables nerve reshaping while accommodating anatomical constraints of various implant locations ranging from peripheral nerves to spinal and autonomic plexi. APPROACH Introduced is a new composite electrode enabling patterning of regions of various electrode mechanical properties. The initial demonstration of the composite's capability is the composite flat interface nerve electrode (C-FINE). The C-FINE is constructed from a sandwich of patterned PEEK within layers of pliable silicone. The shape of the PEEK provides a desired pattern of stiffness: stiff across the width of the nerve to reshape the nerve, but flexible along its length to allow for bending with the nerve. This is particularly important in anatomical locations near joints or organs, and in constrained compartments. We tested pressure and volume design constraints in vitro to verify that the C-FINE can attain a safe cuff-to-nerve ratio (CNR) without impeding intraneural blood flow. We measured nerve function as well as nerve and axonal morphology following 3 month implantation of the C-FINE without wires on feline peripheral nerves in anatomically constrained areas near mobile joints and major blood vessels in both the hind and fore limbs. MAIN RESULTS In vitro inflation tests showed effective CNRs (1.93 ± 0.06) that exceeded the industry safety standard of 1.5 at an internal pressure of 20 mmHg. This is less than the 30 mmHg shown to induce loss of conduction or compromise blood flow. Implanted cats showed no changes in physiology or electrophysiology. Behavioral signs were normal suggesting healthy nerves. Motor nerve conduction velocity and compound motor action potential did not change significantly between implant and explant (p > 0.15 for all measures). Axonal density and myelin sheath thickness was not significantly different within the electrode compared to sections greater than 2 cm proximal to implanted cuffs (p > 0.14 for all measures). SIGNIFICANCE We present the design and verification of a novel nerve cuff electrode, the C-FINE. Laminar manufacturing processes allow C-FINE stiffness to be configured for specific applications. Here, the central region in the configuration tested is stiff to reshape or conform to the target nerve, while edges are highly flexible to bend along its length. The C-FINE occupies less volume than other NCEs, making it suitable for implantation in highly mobile locations near joints. Design constraints during simulated transient swelling were verified in vitro. Maintenance of nerve health in various challenging anatomical locations (sciatic and median/ulnar nerves) was verified in a chronic feline model in vivo.
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Affiliation(s)
- M J Freeberg
- Department of Biomedical Engineering, Case Western Reserve University, Cleveland, OH, United States of America
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Tsai K, Singh D, Pinkhasov A. Pudendal nerve entrapment leading to avoidant/restrictive food intake disorder (ARFID): A case report. Int J Eat Disord 2017; 50:84-87. [PMID: 27539957 DOI: 10.1002/eat.22601] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2016] [Revised: 06/25/2016] [Accepted: 07/13/2016] [Indexed: 11/09/2022]
Abstract
Avoidant/restrictive food intake disorder (ARFID) is a diagnosis in diagnostic and statistical manual of mental disorders-5 (DSM-5) manifested by persistent failure to meet nutritional and/or energy needs. Pudendal nerve entrapment (PNE) often causes pelvic discomfort in addition to constipation and painful bowel movements. Current literature on ARFID is sparse and focuses on the pediatric and adolescent population. No association between PNE and ARFID has been described. We present a case of ARFID in an adult male with PNE resulting from subsequent scarring from testicular cancer surgery. The patient's gastrointestinal symptoms due to PNE caused significant food avoidance and restriction subsequently leading to severe malnourishment. Clinicians should be aware that distressing gastrointestinal symptoms arising from a secondary disease process such as PNE might lead to dietary restriction and food aversion. More research is needed for proper screening, detection, and treatment of ARFID. © 2016 Wiley Periodicals, Inc. (Int J Eat Disord 2017; 50:84-87).
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Affiliation(s)
- Karen Tsai
- Stony Brook University School of Medicine and Department of Behavioral Health, Winthrop University Hospital, Stony Brook, New York
| | - Deepan Singh
- Department of Behavioral Health, Winthrop University Hospital, Mineola, New York
| | - Aaron Pinkhasov
- Department of Behavioral Health, Winthrop University Hospital, Mineola, New York
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Gómez-Hoyos J, Khoury A, Schröder R, Johnson E, Palmer IJ, Martin HD. The Hip-Spine Effect: A Biomechanical Study of Ischiofemoral Impingement Effect on Lumbar Facet Joints. Arthroscopy 2017; 33:101-107. [PMID: 27599822 DOI: 10.1016/j.arthro.2016.06.029] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2015] [Revised: 06/15/2016] [Accepted: 06/15/2016] [Indexed: 02/02/2023]
Abstract
PURPOSE To assess the relation between ischiofemoral impingement (IFI) and lumbar facet joint load during hip extension in cadavers. METHODS Twelve hips in 6 fresh T1-to-toes cadaveric specimens were tested. A complete pretesting imaging evaluation was performed using computed tomography scan. Cadavers were positioned in lateral decubitus and fixed to a dissection table. Both legs were placed on a frame in a simulated walking position. Through a posterior lumbar spine approach L3-4 and L4-5 facet joints were dissected bilaterally. In addition, through a posterolateral approach to the hip, the space between the ischium and the lesser trochanter was dissected and measured. Ultrasensitive, and previously validated, piezoresistive force sensors were placed in lumbar facet joints of L3-4 and L4-5. Lumbar facet loads during hip extension were measured in native hip conditions and after simulating IFI by performing lesser trochanter osteotomy and lengthening. Four paired t-tests were performed comparing normal and simulated IFI on the L3-L4 and L4-L5 facet joint loads. RESULTS After simulating IFI, mean absolute differences of facet joint load were 10.8 N (standard error of the mean [SEM] ±4.53, P = .036) for L3-4 at 10° of hip extension, 13.71 N (SEM ±4.53, P = .012) for L3-4 at 20° of hip extension, 11.49 N (SEM ±4.33, P = .024) for L4-5 at 10° of hip extension, and 6.67 N (SEM ±5.43, P = .245) for L4-5 at 20° of hip extension. A statistically significant increase in L3-4 and L4-5 lumbar facet joint loads of 30.81% was found in the IFI state as compared with the native state during terminal hip extension. CONCLUSIONS Limited terminal hip extension due to simulated IFI significantly increases L3-4 and L4-5 lumbar facet joint load when compared with non-IFI native hips. CLINICAL RELEVANCE This biomechanical study directly links IFI to increased lumbar facet loads and supports the clinical findings of IFI causing lumbar pathology. Assessing and treating (open or endoscopic) hip disorders that limit extension could have benefit in patients with concomitant lower back symptoms.
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Affiliation(s)
- Juan Gómez-Hoyos
- Hip Preservation Center, Baylor University Medical Center at Dallas, Dallas, Texas, U.S.A.; Orthopedic Unit, Clínica Las Américas, Medellín, Colombia; School of Medicine, Universidad de Antioquia, Medellín, Colombia.
| | - Anthony Khoury
- Department of Bioengineering, University of Texas at Arlington, Arlington, Texas, U.S.A
| | - Ricardo Schröder
- Hip Preservation Center, Baylor University Medical Center at Dallas, Dallas, Texas, U.S.A
| | - Eric Johnson
- College of Medicine, University of Oklahoma, Oklahoma City, Oklahoma, U.S.A
| | - Ian J Palmer
- Hip Preservation Center, Baylor University Medical Center at Dallas, Dallas, Texas, U.S.A
| | - Hal D Martin
- Hip Preservation Center, Baylor University Medical Center at Dallas, Dallas, Texas, U.S.A
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Weissman E, Boothe E, Wadhwa V, Scott K, Chhabra A. Magnetic Resonance Neurography of the Pelvic Nerves. Semin Ultrasound CT MR 2016; 38:269-278. [PMID: 28705371 DOI: 10.1053/j.sult.2016.11.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Chronic pelvic pain syndrome is commonly caused by nerve injury, inflammation, or entrapment. Owing to the complex anatomy and branching patterns of pelvic nerves, pelvic neuropathies are often difficult to illustrate and diagnose. High-resolution 3-T magnetic resonance neurography is a promising technique for the evaluation of peripheral neuropathy. In this article, the authors discuss the normal anatomy of major pelvic nerves, technical considerations of high-resolution imaging, and normal and abnormal imaging appearances with relevant case examples.
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Affiliation(s)
- Eric Weissman
- Department of Radiology, University of Texas Southwestern Medical Center, Dallas, TX
| | - Ethan Boothe
- Department of Radiology, University of Texas Southwestern Medical Center, Dallas, TX
| | - Vibhor Wadhwa
- Department of Radiology, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Kelly Scott
- Department of Physical Medicine & Rehabilitation, University of Texas Southwestern Medical Center, Dallas, TX
| | - Avneesh Chhabra
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX; Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX.
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Fritz J, Fritz B, Dellon AL. Sacrotuberous Ligament Healing following Surgical Division during Transgluteal Pudendal Nerve Decompression: A 3-Tesla MR Neurography Study. PLoS One 2016; 11:e0165239. [PMID: 27828983 PMCID: PMC5102410 DOI: 10.1371/journal.pone.0165239] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Accepted: 10/07/2016] [Indexed: 11/18/2022] Open
Abstract
Pelvic pain due to chronic pudendal nerve (PN) compression, when treated surgically, is approached with a transgluteal division of the sacrotuberous ligament (STL). Controversy exists as to whether the STL heals spontaneously or requires grafting. Therefore, the aim of this study was to determine how surgically divided and unrepaired STL heal. A retrospective evaluation of 10 patients who had high spatial resolution 3-Tesla magnetic resonance imaging (3T MRI) exams of the pelvis was done using an IRB-approved protocol. Each patient was referred for residual pelvic pain after a transgluteal STL division for chronic pudendal nerve pain. Of the 10 patients, 8 had the STL divided and not repaired, while 2 had the STL divided and reconstructed with an allograft tendon. Of the 8 that were left unrepaired, 6 had bilateral surgery. Outcome variables included STL integrity and thickness. Normative data for the STL were obtained through a control group of 20 subjects. STL integrity and thickness were measured directly on 3 T MR Neurography images, by two independent Radiologists. The integrity and thickness of the post-surgical STL was evaluated 39 months (range, 9-55) after surgery. Comparison was made with the native contra-lateral STL in those who had unilateral STL division, and with normal, non-divided STL of subjects of the control group. The normal STL measured 3 mm (minimum and maximum of absolute STL thickness, 2-3 mm). All post-operative STL were found to be continuous regardless of the surgical technique used. Measured at level of Alcock's canal in the same plane as the obturator internus tendon posterior to the ischium, the mean anteroposterior STL diameter was 5 mm (range, 4-5 mm) in the group of prior STL division without repair and 8 mm (range, 8-9 mm) in the group with the STL reconstructed with grafts (p<0.05). The group of healed STLs were significantly thicker than the normal STL (p<0.05). We conclude that a surgically divided STL will heal spontaneously and will be significantly thicker after healing.
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Affiliation(s)
- Jan Fritz
- Russell H. Morgan Department of Radiology and Radiological Science, The Johns Hopkins University School of Medicine, 600 N Wolfe St., Baltimore, MD, 21287, United States of America
| | - Benjamin Fritz
- Department of Radiology, Orthopedic University Hospital Balgrist, Forchstrasse 340, 8008, Zurich, Switzerland
| | - A. Lee Dellon
- Department of Plastic and Reconstructive Surgery, The Johns Hopkins University School of Medicine, 600 N Wolfe St., Baltimore, MD, 21287, United States of America
- * E-mail:
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Persistent Genital Arousal Disorder: A Review of Its Conceptualizations, Potential Origins, Impact, and Treatment. Sex Med Rev 2016; 4:329-42. [DOI: 10.1016/j.sxmr.2016.06.003] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Revised: 06/17/2016] [Accepted: 06/18/2016] [Indexed: 11/22/2022]
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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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Doggweiler R, Whitmore KE, Meijlink JM, Drake MJ, Frawley H, Nordling J, Hanno P, Fraser MO, Homma Y, Garrido G, Gomes MJ, Elneil S, van de Merwe JP, Lin ATL, Tomoe H. A standard for terminology in chronic pelvic pain syndromes: A report from the chronic pelvic pain working group of the international continence society. Neurourol Urodyn 2016; 36:984-1008. [PMID: 27564065 DOI: 10.1002/nau.23072] [Citation(s) in RCA: 108] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2016] [Accepted: 05/23/2016] [Indexed: 12/27/2022]
Abstract
AIMS Terms used in the field of chronic pelvic pain (CPP) are poorly defined and often confusing. An International Continence Society (ICS) Standard for Terminology in chronic pelvic pain syndromes (CPPS) has been developed with the aim of improving diagnosis and treatment of patients affected by chronic pelvic pain syndromes. The standard aims to facilitate research, enhance therapy development and support healthcare delivery, for healthcare providers, and patients. This document looks at the whole person and all the domains (organ systems) in a systematic way. METHODS A dedicated working group (WG) was instituted by the ICS Standardisation Steering Committee according to published procedures. The WG extracted information from existing relevant guidelines, consensus documents, and scientific publications. Medline and other databases were searched in relation to each chronic pelvic pain domain from 1980 to 2014. Existing ICS Standards for terminology were utilized where appropriate to ensure transparency, accessibility, flexibility, and evolution. Consensus was based on majority agreement. RESULTS The multidisciplinary CPPS Standard reports updated consensus terminology in nine domains; lower urinary tract, female genital, male genital, gastrointestinal, musculoskeletal, neurological aspects, psychological aspects, sexual aspects, and comorbidities. Each is described in terms of symptoms, signs and further evaluation. CONCLUSION The document presents preferred terms and definitions for symptoms, signs, and evaluation (diagnostic work-up) of female and male patients with chronic pelvic pain syndromes, serving as a platform for ongoing development in this field. Neurourol. Urodynam. 36:984-1008, 2017. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
| | - Kristene E Whitmore
- Chair of Urology and Female Pelvic Medicine and Reconstructive Surgery, Drexel University College of Medicine, Philadelphia, Pennsylvania
| | - Jane M Meijlink
- International Painful Bladder Foundation, Naarden, Netherlands
| | - Marcus J Drake
- Department of Urology, School of Clinical Sciences, University of Bristol, Bristol, United Kingdom
| | - Helena Frawley
- Physiotherapy at La Trobe University, Melbourne, Cabrini Health, Melbourne, Australia
| | - Jørgen Nordling
- Department of Urology, University of Copenhagen, Herlev Hospital, Herlev, Denmark
| | - Philip Hanno
- Department of Urology, Division of Urology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Matthew O Fraser
- Department of Urology Surgery, Duke University and Durham Veterans Affairs Medical Centers, Durham, North Carolina
| | - Yukio Homma
- Department of Urology, The University of Tokyo, Tokyo, Japan
| | - Gustavo Garrido
- Head of Voiding Dysfunctions and Urodynamics Section, Urology Division, Hospital de Clínicas, University of Buenos Aires, Argentina
| | - Mario J Gomes
- Department of Urology, St. António Hospital, Oporto, Portugal
| | - Sohier Elneil
- Department of Urogynecology, University College Hospital, National Hospital for Neurology and Neurosurgery, GB
| | | | - Alex T L Lin
- Department of Urology, Taipei Veterans General Hospital, National Yang Ming University, Taipei, Taiwan
| | - Hikaru Tomoe
- Department of Urogynecology, Chair of Pelvic Reconstructive Surgery and Urology, Tokyo Women's Medical University Medical Center East, Japan
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Konschake M, Brenner E, Moriggl B, Hörmann R, Bauer S, Foditsch E, Janetschek G, Künzel KH, Sievert KD, Zimmermann R. New laparoscopic approach to the pudendal nerve for neuromodulation based on an anatomic study. Neurourol Urodyn 2016; 36:1069-1075. [PMID: 27490402 DOI: 10.1002/nau.23090] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2016] [Accepted: 07/13/2016] [Indexed: 11/09/2022]
Abstract
AIMS The aim was to develop a new laparoscopic technique for placement of a pudendal lead. METHODS Development of a direct, feasible and reliable minimal-invasive laparoscopic approach to the pudendal nerve (PN). Thirty-one embalmed human specimens were dissected for the relevant anatomic structures of the pelvis. Step-by-step documentation and analysis of the laparoscopic approach in order to locate the PN directly in its course around the medial part of the sacrospinous ligament and test this approach for feasibility. Landmarks for intraoperative navigation towards the PN as well as the possible position of an lead were selected and demonstrated. RESULTS The visible medial umbilical fold, the intrapelvine part of the internal pudendal artery, the coccygeus muscle and the sacrospinous ligament are the main landmarks. The PN traverses the medial part of the sacrospinous ligament dorsally, medially to the internal pudendal artery. The medial part of the sacrospinous ligament has to be exposed in order to display the nerve. An lead can be placed ventrally on the nerve or around it, depending on the lead type or shape. CONCLUSIONS A precise and reliable identification of the PN by means of laparoscopy is feasible with an easy four-step approach: (1) identification of the medial umbilical fold; (2) identification of the internal iliac artery; (3) identification of the internal pudendal artery and incision of the coccygeus muscle ('white line', arcuated line); and (4) exposition of the medial part of the sacrospinous ligament to display the PN.
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Affiliation(s)
- Marko Konschake
- Division for Clinical and Functional Anatomy, Department of Anatomy, Histology and Embryology, Medical University of Innsbruck, Tirol, Austria
| | - Erich Brenner
- Division for Clinical and Functional Anatomy, Department of Anatomy, Histology and Embryology, Medical University of Innsbruck, Tirol, Austria
| | - Bernhard Moriggl
- Division for Clinical and Functional Anatomy, Department of Anatomy, Histology and Embryology, Medical University of Innsbruck, Tirol, Austria
| | - Romed Hörmann
- Division for Clinical and Functional Anatomy, Department of Anatomy, Histology and Embryology, Medical University of Innsbruck, Tirol, Austria
| | - Sophina Bauer
- Department of Urology and Andrology, SALK University Clinic and Paracelsus Private Medical University, Salzburg, Austria
| | - Esra Foditsch
- Department of Urology and Andrology, SALK University Clinic and Paracelsus Private Medical University, Salzburg, Austria
| | - Günther Janetschek
- Department of Urology and Andrology, SALK University Clinic and Paracelsus Private Medical University, Salzburg, Austria
| | - Karl-Heinz Künzel
- Division for Clinical and Functional Anatomy, Department of Anatomy, Histology and Embryology, Medical University of Innsbruck, Tirol, Austria
| | - Karl-Dietrich Sievert
- Department of Urology and Andrology, SALK University Clinic and Paracelsus Private Medical University, Salzburg, Austria
| | - Reinhold Zimmermann
- Department of Urology and Andrology, SALK University Clinic and Paracelsus Private Medical University, Salzburg, Austria
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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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Ischiofemoral Impingement and Hamstring Syndrome as Causes of Posterior Hip Pain: Where Do We Go Next? Clin Sports Med 2016; 35:469-486. [PMID: 27343397 DOI: 10.1016/j.csm.2016.02.010] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Recent advances in understanding hip joint anatomy and biomechanics have contributed to improvement of diagnosis and treatment decisions for distal causes of deep gluteal syndrome (DGS). Ischiofemoral impingement and hamstrings syndrome are sources of posterior hip pain that can simulate symptoms of DGS. The combination of a comprehensive history and physical examination with imaging and ancillary testing are critical for diagnosis. Six key physical examination tests are described to differentiate distal versus proximal sources of extrapelvic posterior hip pain. Outcomes depend on patient compliance and the understanding of the entire anatomy, biomechanics, clinical presentation, and open versus endoscopic treatment options.
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The Role of Pelvic Floor Muscles in Male Sexual Dysfunction and Pelvic Pain. Sex Med Rev 2016; 4:53-62. [DOI: 10.1016/j.sxmr.2015.10.001] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2015] [Accepted: 08/02/2015] [Indexed: 12/22/2022]
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