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Decompression and Transposition of the Pudendal Nerve in Pudendal Neuralgia: A Randomized Controlled Trial and Long-Term Evaluation
Abstract
We assess that pudendal neuralgia is a tunnel syndrome due to a ligamentous entrapment of the pudendal nerve and have treated 400 patients surgically since 1987. We have had no major complication. We conducted a randomized controlled trial to evaluate our procedure.
A sequential, randomized controlled trial to compare decompression of the pudendal nerve with non-surgical treatment. Patients aged 18-70, had chronic, uni/bilateral perineal pain, positive temporary response to blocks at the ischial spine and in Alcock's canal. They were randomly assigned to surgery (n=16) and control (n=16) groups. Primary end point was improvement at 3 months following surgery or assignment to the non-surgery group. Secondary end points were improvement at 12 months and at 4 years following surgical intervention.
A significantly higher proportion of the surgery group was improved at 3 months. On intention-to-treat analysis 50% of the surgery group reported improvement in pain at 3 months versus 6.2% of the non-surgery group (p=.0155); in the analysis by treatment protocol the figures were 57.1% versus 6.7% (p=.0052). At 12 months, 71.4% of the surgery group compared with 13.3% of the non-surgery group were improved, analyzing by treatment protocol (p=.0025). Only those randomized to surgery were evaluated at 4 years: 8 remained improved at 4 years. No complications were encountered.
In this study we demonstrate that decompression of the pudendal nerve is an effective and safe treatment for cases of chronic pudendal neuralgia that have been unresponsive to analgesia and nerve blocks. Following surgery, other medical interventions may be necessary.
... Among the included studies, 11 were retrospective [12-17, 22, 26, 29, 36, 38], 11 were prospective [10,18,19,21,23,28,[31][32][33][34][35], 7 were case reports [11,20,25,27,30,37,39], and one was a randomized trial [24]. The surgical techniques utilized exhibited variation, encompassing transperineal open surgery in 8 studies [10][11][12][13][14][15][16][17], transgluteal in 8 studies [18][19][20][21][22][23][24][25], and the remainder adopting minimally invasive approaches, which comprised 12 laparoscopic [26][27][28][29][30][31][32][33][34][35][36][37] and 2 robot-assisted [38,39] methods. ...
... Among the included studies, 11 were retrospective [12-17, 22, 26, 29, 36, 38], 11 were prospective [10,18,19,21,23,28,[31][32][33][34][35], 7 were case reports [11,20,25,27,30,37,39], and one was a randomized trial [24]. The surgical techniques utilized exhibited variation, encompassing transperineal open surgery in 8 studies [10][11][12][13][14][15][16][17], transgluteal in 8 studies [18][19][20][21][22][23][24][25], and the remainder adopting minimally invasive approaches, which comprised 12 laparoscopic [26][27][28][29][30][31][32][33][34][35][36][37] and 2 robot-assisted [38,39] methods. Table 1 shows the characteristics of the included papers. ...
... The transgluteal open surgical technique for PNN, as pioneered by Robert et al. [41], entails positioning the patient in a prone jack-knife position under general anesthesia. This approach has been consistently adopted across various medical centers without variations [18][19][20][21][22][23][24][25]. ...
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.
... . Accordingly, a posterior transgluteal approach was suggested for pudendal nerve decompression in case of refractory pudendal neuralgia [4][5][6]. However, the posterior approach was effective only in about two-thirds of the patients treated [4][5][6]. ...
... . Accordingly, a posterior transgluteal approach was suggested for pudendal nerve decompression in case of refractory pudendal neuralgia [4][5][6]. However, the posterior approach was effective only in about two-thirds of the patients treated [4][5][6]. ...
... The traditionally known anatomical pathway of the pudendal nerve involves the origin of S2, S3, and S4 spinal roots, along a single pudendal nerve trunk, and division into the inferior rectal, perineal, and dorsal nerves within the Alcock's canal (Fig. 3) [1,5]. Since the pudendal neurovascular bundle, presumed to occur in the form of a single nerve trunk, is known to be generally compressed in the interval between the sacrotuberous and sacrospinous ligaments, it should be identified in the space exposed by incision of the sacrotuberous ligament during the posterior transgluteal approach [1,5]. ...
... In the assessment of risk of bias among the 19 included studies, represented in Fig. 2, 31% (6 studies) were rated as 'Good' or 'Very good,' 37% (7 studies) as 'Intermediate,' and 31% (6 studies) were classified as 'Poor quality.' Important in the bias assessement is the presence of only one randomized clinical trail, Robert et al. [18] All other studies are case series, either pro-or retrospective. None of the studies were blinded. ...
... The transgluteal approach, pioneered by Robert et al., gives access to both the pudendal and the cluneal nerve [18]. Upon dividing the STL, the pudendal nerve becomes fully visible, extending from the piriformis muscle to the Alcock's canal. ...
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.
... Нервно-мышечные Б О Л Е З Н И Neuromuscular DISEASES 4'2023 ТОМ 13 VOL. 13 [9,64,65]. В послеоперационном периоде рекомендуется медикаментозная поддержка до 24 мес вследствие присущей ПН центральной сенситизации. ...
... Следует отметить, что до 30 % пациентов, перенесших оперативное вмешательство, не отмечают эффекта, еще у 1/3 пациентов происходит рецидивирование симптоматики, что ведет к повторной операции [66,67]. Причинами рецидива могут выступать необратимые повреждения нерва вследствие длительной компрессии, неполная хирургическая декомпрессия и послеоперационный рубцово-спаечный процесс, ведущий к повторному ущемлению полового нерва [65]. Краткий алгоритм лечения ПН может быть представлен в виде следующей схемы (рис. ...
Pudendal neuralgia is the most common type of neurogenic chronic pelvic pain and is defined as a chronic neuropathic pain syndrome caused by compression and/or neuropathy of the genital nerve and localized in the area of its sensory innervation. Pudendal neuralgia negatively affects daily activity and reduces the quality of life. The diagnosis of pudendal neuralgia is established on the basis of clinical manifestations and examination data in accordance with the Nantes criteria, while instrumental methods (ultrasound, magnetic resonance and computed tomography, electrodiagnostic methods) do not allow verifying the diagnosis due to significant limitations. Currently, there are no unambiguous recommendations and standards for the treatment of pudendal neuralgia, however, a combination of different methods and a personalized approach allows in some cases to achieve significant success and long-term pain control. The article highlights in detail the anatomical features of the pudendal nerve, examines the possibilities and stages of diagnosis of pudendal neuralgia, and provides an overview of therapeutic methods from the standpoint of evidence-based medicine.
... Despite the medical therapy's positive influence on the incidence and severity of chronic postsurgical pain during the perioperative period [13], nerve decompression is the only option that guarantees long-term outcomes. In a randomized controlled trial, surgical treatment determined an improvement in pain immediately after 3 months in patients compared to the control group, 57.1% vs 6.7%, and then increased the gap at 12 months of follow-up, 71.4% vs 13.3% [14]. ...
... Several open techniques were proposed according to the site of PN branch involvement: transischiorectal and transperineal (anterior) incision, despite a limited field of view, and transgluteal (posterior) incision, with a higher rate of surgical trauma. Therefore, the site-specific open approach choice for the surgery is preferable for optimal functional outcomes [14]. Laparoscopic surgery was introduced by Possover to reduce postoperative comorbidities and minimize scarring [15]. ...
Objective
Pudendal Nerve Entrapment (PNE) may determine chronic pelvic pain associated with symptoms related to its innervation area. This study aimed to present the technique and report the outcomes of the first series of robot-assisted pudendal nerve release (RPNR).
Patients and methods
32 patients, who were treated with RPNR in our centre between January 2016 and July 2021, were recruited. Following the medial umbilical ligament identification, the space between this ligament and the ipsilateral external iliac pedicle is progressively dissected to identify the obturator nerve. The dissection medial to this nerve identifies the obturator vein and the arcus tendinous of the levator ani, which is cranially inserted into the ischial spine. Following the cold incision of the coccygeous muscle at the level of the spine, the sacrospinous ligament is identified and incised. The pudendal trunk (vessels and nerve) is visualized, freed from the ischial spine and medially transposed.
Results
The Median duration of symptoms was 7 (5, 5–9) years. The median operative time was 74 (65–83) minutes. The median length of stay was 1 (1–2) days. There was only a minor complication. At 3 and 6 months after surgery, a statistically significant pain reduction has been encountered. Furthermore, the Pearson correlation coefficient reported a negative relationship between the duration of pain and the improvement in NPRS score, − 0.81 (p = 0.01).
Conclusions
RPNR is a safe and effective approach for the pain resolution caused by PNE. Timely nerve decompression is suggested to enhance outcomes.
... Despite the medical therapy's positive influence on the incidence and severity of chronic postsurgical pain during the perioperative period [13], nerve decompression is the only option that guarantees long-term outcomes. In a randomized controlled trial, surgical treatment determined an improvement in pain immediately after 3 months in patients compared to the control group, 57.1% vs 6.7%, and then increased the gap at 12 months of follow-up, 71.4% vs 13.3% [14]. ...
... Several open techniques were proposed according to the site of PN branch involvement: transischiorectal and transperineal (anterior) incision, despite a limited field of view, and transgluteal (posterior) incision, with a higher rate of surgical trauma. Therefore, the site-specific open approach choice for the surgery is preferable for optimal functional outcomes [14]. Laparoscopic surgery was introduced by Possover to reduce postoperative comorbidities and minimize scarring [15]. ...
... Surgical decompression on PNE has been used as a last resort for refractory patients, with success rates between 53 and 83% [12]. A randomized controlled study [15] also proved the efficacy of PN surgical decompression, with a success ratio of 71% by the 12 th month. However, it is described in the literature that around 25 to 40% of patients do not respond to surgery because they do not have a clear diagnosis [1]. ...
Purpose
Pudendal nerve entrapment (PNE) diagnosis is not standardized. This leads to diagnosis delays, impacting quality of life and therapeutic outcomes. The main goal is to find the role of neurophysiological study (NFS) and Imaging-guided pudendal nerve infiltration (ImPNI) in PNE diagnosis and patient selection for surgery.
Methods
A retrospective, multicentric study was conducted. Patients with PNE refractory to conservative treatment were included. Patient data, including NFS results, ImPNI, and surgical outcomes, were evaluated. A visual analogue scale was used to assess intervention response. Test performance metrics for NFS and ImPNI and binary logistic regression were used to determine their predictive value for postoperative improvement.
Results
88 patients were diagnosed with PNE. All had NFS, and ImPNI was performed in 69 (78.4%), with 60 (68.2%) showing symptom improvement. Among the 40 patients (85%) who underwent pudendal nerve decompression surgery, 75% improved after surgery, and 20% did not.
The combination of NFS and ImPNI showed a sensitivity of 79% and a specificity of 85.7%, with a Positive Predictive Value (PPV) of 98% and a Negative Predictive Value (NPV) of 30%. NFS and ImPNI were significant predictors of surgical success with p-values of 0.013 [ 95% CI: -23.6—19.9] and 0.003 [95% CI: -20.6 -18.5], respectively. Primary limitations: retrospective design and the absence of a control group.
Conclusions
NFS and ImPNI are essential and highly reliable tools for diagnosing PNE. ImPNI is a valuable predictor of surgical outcomes. These findings enable precise patient selection for surgery, ensuring optimal surgical outcomes.
... Several studies have explored the effectiveness of pudendal nerve infiltration and surgical decompression, reporting significant improvements in pain and function [3,19,20,25,37,38]. However, these studies did not assess the impact of treatment timing. ...
Background: Chronic pelvic pain (CPP) associated with pudendal neuralgia (PN) significantly impacts quality of life (QoL). Pudendal nerve infiltration is a recognized treatment, but the optimal timing of intervention remains unclear. Methods: This prospective study included 81 patients diagnosed with PN and treated with pudendal nerve infiltrations. Outcomes were assessed using the Visual Analog Scale (VAS), Spanish Pain Questionnaire (CDE–McGill), and the SF-12 health survey. Significant improvement was defined as a VAS reduction > 4 points and a QoL increase > 15 points. An ROC curve analysis identified a 13-month time-to-treatment threshold (sensitivity 78%, specificity 72%), categorizing patients into early (n = 27) and delayed treatment groups (n = 54). Results: The early treatment group showed significantly greater reductions in VAS scores (5.4 vs. 3.4 points, p < 0.01) and QoL improvements (18 vs. 8 points, p < 0.01) compared to the delayed group. Early intervention reduced reinfiltration rates (10% vs. 35%, p < 0.05) and decreased medication use, with 81% discontinuing gabapentin compared to 41% in the delayed group. Similar trends were observed for tryptizol (44% vs. 35%) and tramadol (74% vs. 30%). Multivariate analysis confirmed time to treatment as the strongest predictor of outcomes, with each additional month delaying treatment associated with a 0.18-point increase in final VAS scores (p < 0.001). Delayed treatment was linked to higher final doses of gabapentin (p = 0.01), dexketoprofen (p < 0.001), and tramadol (p = 0.012). Minimal complications were reported (15%, Clavien I). Conclusions: Early intervention in PN significantly improves pain, QoL, and reduces reinfiltration and medication reliance, supporting timely treatment for optimal outcomes.
... 2,3 Long-term cures are possible. 4 A physician-patient, disabled by pudendal neuropathy, stated that "…having to struggle with the pain and disability of PN has been a terrible burden on my family, has cut short my career as an ophthalmic surgeon after only nine years, and, at times, has even made me wish for death." "It is a diagnosis that must be made urgently before neuropathic pain and/or urinary, rectal, and genital dysfunctions become chronic, disabling, and resistant to treatment." ...
Aims
(1) To use intraoperative photographs to visualize and explain pudendal nerve compressions and anatomical variations of compression sites in patients with chronic pelvic pain. (2) To emphasize the diagnostic importance of sensory examination with a safety pin at the six pudendal nerve branches in all patients with chronic pelvic pain; the dorsal nerves (penis or clitoris; the perineal nerves; and the inferior rectal nerves).
Methods
Between 2003 and 2014, “definite” pudendal neuropathy was diagnosed by examination and with two neurophysiologic tests. Neurolysis, via a transgluteal approach, was recommended only after 14 weeks of conservative care failed to adequately improve symptoms and validated symptom scores. Photographs of surgical findings were culled for their educational impact. An illustration of each photo clarifies the surgical anatomy.
Results
The transgluteal incision permits access to pudendal anatomy and compression sites from the subpiriformis area through the interligamentary space and the pudendal canal (Alcock canal). Compressions were acquired or congenital and severity varied significantly. Pinprick sensory testing diagnoses pudendal neuropathy in 92% of both genders. Mid‐nerve compression occurred commonly between the sacrotuberous and sacrospinous ligaments less frequently in the Alcock canal, but also at aberrant pathways, for example, between layers of the sacrotuberous ligament; a separate inferior rectal nerve passing through the sacrospinous ligament; at an anomalous lateral pathway posterior to the ischial spine. The results of international surgeons are discussed.
Conclusions
Decompression surgery was recommended in approximately 35% of patients in this practice, when pudendal neuropathy (pudendal syndrome), did not respond to two conservative levels of treatment: (1) nerve protection and medications and, (2) a series of three pudendal nerve perineural injections given at 4‐week intervals. Significant nerve compression is consistently observed. Pathophysiology includes axonopathy from ischemia and demyelination. Neuropathy is readily diagnosed using a pinprick sensory examination of six pudendal nerve branches. Monitoring with the National Institutes of Health Chronic Prostatitis Symptom Index records cures >13 years.
... A multimodal approach to treatment is often necessary for patients with chronic pelvic pain. Interventional and neuromodulatory procedures can be applied for diagnostic evaluation and treatment, often once more conservative measures have failed to provide relief [40,41]. ...
Objectives: Here, we review opioid-sparing or opioid-free anesthesia and pain management for urologic procedures and pathologies–urological pain syndromes, kidney stone pain management, development of post-surgical pain syndromes, and prevention. We explore acute management of perioperative pain during and after urologic procedures; additionally, we review the pathophysiology of various urologic pain syndromes along with a variety of interventions, including pharmacologic management, nerve blocks, neurolysis, and neuromodulatory therapies in hopes of educating providers who treat the urologic patient. Methods: Relevant literature on various topics related to acute and chronic urologic pain was reviewed and incorporated into this comprehensive overview. Relevant clinical treatments and treatment guidelines for managing pain related to various urological conditions and syndromes are discussed, compared, and contrasted and conclusions are drawn. Results and Discussion: Urological pathologies, procedures, pain syndromes and their pharmacologic and interventional pain management strategies are discussed. Conclusion: Acute and chronic pain remain essential components of postoperative morbidity, both in the urologic patient and otherwise. The opioid epidemic has further complicated perioperative management, but effective pain control is vital to improving patient outcomes. Close collaboration between urologists, anesthesiologists, and pain specialists is critical in improving patient care.
... The According to the updated European Association of Urology guidelines, nerve decompression through PNN is particularly recommended for carefully selected patients who have failed conservative therapies for chronic pelvic pain associated with PNE [6]. Nerve decompression is the only option that ensures long-term outcomes [7]. ...
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.
... Si celle-ci est une douleur neuropathique spontanée, dans le territoire d'une ou des branches du nerf pudendal, l'origine pudendale peut être évoquée. Les différents traitements de la NP (infiltration, neurolyse chirurgicale, neuromodulation) ont été rapportés dans la littérature avec des taux significatifs d'amélioration, voire de guérison [56,[60][61][62][63][64] . ...
... The perforating nerve of the sacrotuberous ligament is often said to be well associated with pudendal nerve entrapment syndrome, which often causes chronic perineal pain (Shafik et al. 1995;Robert et al. 1998;Loukas et al. 2006). Therefore, the ligament is sometimes incised to treat the entrapment (Mauillon et al. 1999;Robert et al. 2005Robert et al. , 2007Popeney et al. 2007;Filler 2009). The perforating nerve has been reported in recent years by Shafarenko et al. (2022), and their report was similar to that of Eisler (1891). ...
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.
... Should these treatments fail, surgical decompression is often used for patients who respond to diagnostic nerve blocks. However, 30% of PN surgical decompression patients experience no pain relief (9). The last-resort treatment for intractable PN has been a trial of neuromodulation followed by permanent implantation of electrodes using fluoroscopic guidance. ...
BACKGROUND: Pudendal neuralgia (PN) can cause severe, disabling chronic pain. Though common, PN is frequently unrecognized and misdiagnosed. Historically, the last-resort treatment for PN has been permanent implantation of spinal cord stimulation (SCS), but SCS for PN carries high risk of complications and explantation. We report the first case of temporary (60-day) peripheral nerve stimulation (PNS) treatment for refractory PN. CASE REPORT: A 63-year-old woman presented with one year of chronic bilateral suprapubic vaginal pain radiating to the bilateral proximal medial thighs with concomitant dysuria, urinary frequency, and pain with intercourse. PN was confirmed via diagnostic pudendal nerve block. Using fluoroscopic guidance, we implanted PNS leads on the left and, subsequently, the right pudendal nerves, with explantation at 60 days for each lead. The patient reported continuing pain reduction with 80% improvement in the Visual Analog Scale score at 6 months, resumption of normal activity and functionality, discontinued use of opioids, and high satisfaction with treatment. This case is notable for the sustained pain relief provided by this temporary and minimally invasive treatment. CONCLUSIONS: This case suggests that 60-day PNS with fluoroscopic guidance is a viable treatment for refractory PN in correctly selected patients. This treatment is low-risk, minimally invasive, and may be used early in the care continuum, potentially sparing patients multiple failed treatments and the risks associated with permanently implanted devices. KEY WORDS: Pudendal nerve, peripheral nerve stimulation, neuromodulation, chronic pain, pelvic pain, perineal pain, case report
... However, there is lack of any larger prospective trials evaluating the long-term safety and efficacy of cryotherapy. Surgical options include pudendal nerve release, which aims to release the nerve from compression or entrapment and can be done by open or endoscopic surgery, and pudendal nerve decompression, which aims to relieve pressure on the nerve by removing surrounding tissue or bone that may be compressing it [19,20]. It is important to note that treatment options should be individualized and tailored to each person's specific needs, surgery should be considered as a last resort when non-surgical options have failed, and it is also important to work closely with a healthcare provider to monitor the effectiveness of treatment and adjust as needed [21]. ...
Dorsal root ganglion stimulation is a relatively new treatment option for chronic pain conditions such as pudendal neuralgia, which is a chronic pain condition affecting the pudendal nerve in the pelvic region. Pudendal neuralgia is a debilitating condition that can significantly affect the patient's quality of life. In dorsal root ganglion stimulation, a small device is implanted that delivers electrical impulses to the dorsal root ganglion to modulate pain signals coming from the pudendal nerve. The procedure is considered investigational and has been investigated in case series and case reports with promising results. However, more research is needed to fully understand its safety and effectiveness. This case report highlights the potential of dorsal root ganglion stimulation as a treatment option for pudendal neuralgia and the need for further research to establish it as a standard treatment option.
... 106 and 1 on frozen shoulder. 100 Thirty trials 1,3,8,11,21,23,26,28,32,34,42,47,54,59,62,66,69,71,73,76,81,85,87,92,96,101,105,115,121,126 were at high risk of bias, mainly no blinding of participants, intervention providers, and assessors; large number of crossovers to surgery; and few available statistical analysis plans and/or protocols. ...
Objective:
To estimate the benefits and harms of interventions with and without surgery for musculoskeletal (MSK) conditions.
Design:
Intervention systematic review with meta-analysis of randomized controlled trials (RCTs).
Literature search:
MEDLINE, EMBASE, CINAHL, Web of Science, and CENTRAL, all up to January 7, 2021.
Study selection criteria:
RCTs (English, German, Danish, Swedish, and Norwegian) of interventions with and without surgery conducted in any setting for any non-fracture MSK condition in adults (mean age: 18+ years) evaluating the outcomes on a continuous (benefits) or count (harms) scale. Outcomes were pain, self-reported physical function, quality of life, serious adverse events (SAEs), and death at 1 year.
Data synthesis:
Random-effects metaanalyses for MSK conditions where there were data from at least 2 trials.
Results:
One hundred RCTs (n = 12 645 patients) across 28 different conditions at 9 body sites were included. For 9 out of 13 conditions with data on pain (exceptions include some spine conditions), 11 out of 11 for function, and 9 out of 9 for quality of life, there were no clinically relevant differences (standardized mean difference of 0.50 or above) between interventions with and without surgery. For 13 out of 16 conditions with data on SAEs and 16 out of 16 for death, there were no differences in harms. Only 6 trials were at low risk of bias.
Conclusion:
The low certainty of evidence does not support recommending surgery over nonsurgical alternatives for most MSK conditions with available RCTs. Further high-quality RCTs may change this conclusion. J Orthop Sports Phys Ther 2022;52(6):312-344. doi:10.2519/jospt.2022.11075.
... Surgical decompression of the pudendal nerve has been proven effective for patients in whom other treatments have failed. 32 Open, laparoscopic, and subgluteal endoscopic approaches for pudendal pain described in the literature include the endoscopic transgluteal minimally invasive technique. 33 Pudendal nerve stimulation using this technique after neurolysis has also shown some success. ...
Chronic anal pain is difficult to diagnose and treat, especially with no obvious anorectal cause apparent on clinical examination. This review identifies 3 main diagnostic categories for chronic anal pain: local causes, functional anorectal pain, and neuropathic pain syndromes. Conditions covered within these categories include proctalgia fugax, levator ani syndrome, pudendal neuralgia, and coccygodynia. The signs, symptoms, relevant diagnostic tests, and main treatments for each condition are reviewed.
... Raw examination of the included studies shows that surgery, with no preferential site, seems to be the most efficient therapeutic approach: pain is significantly relieved [36][37][38][39], sometimes even completely [32,40]. In all articles dedicated to this type of treatment, the patients' QoL is reported as considerably improved, ensuring a return to optimal social life and overall health status. ...
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.
... We noticed a lack of prospective, randomised, controlled articles. Only one (Robert et al., 2005) presents high methodological quality. ...
Background:
Since the development and publication of diagnostic criteria for pudendal nerve entrapment (PNE) syndrome in 2008, no comprehensive work has been published on the clinical knowledge in the management of this condition. The aim of this work was to develop recommendations on the diagnosis and the management of PNE.
Methods:
The methodology of this study was based on French High Authority for Health Method for the development of good practice and the literature review was based on the PRISMA method. The selected articles have all been evaluated according to the American Society of Interventional Pain Physicians assessment grid.
Results:
The results of the literature review and expert consensus are incorporated into 10 sections to describe diagnosis and management of PNE: (1) diagnosis of PNE, (2) patients advice and precautions, (3) drugs treatments, (4) physiotherapy, (5) transcutaneous electrostimulations (TENS), (6) psychotherapy, (7) injections, (8) surgery, (9) pulsed radiofrequency, and (10) Neuromodulation. The following major points should be noted: (i) the relevance of 4+1 Nantes criteria for diagnosis; (ii) the preference for initial monotherapy with tri-tetracyclics or gabapentinoids; (iii) the lack of effect of opiates, (iv) the likely relevance (pending more controlled studies) of physiotherapy, TENS and cognitive behavioural therapy; (v) the incertitudes (lack of data) regarding corticoid injections, (vi) surgery is a long term effective treatment and (vii) radiofrequency needs a longer follow-up to be currently proposed in this indication.
Conclusion:
These recommendations should allow rational and homogeneous management of patients suffering from PNE. They should also allow to shorten the delays of management by directing the primary care.
Significance:
Pudendal nerve entrapment (PNE) has only been known for about 20 years and its management is heterogeneous from one practitioner to another. This work offers a synthesis of the literature and international experts' opinions on the diagnosis and management of PNE.
... It may be due to the entrapment and mechanical injury of the pudendal nerve. The common entrapment sites are the sciatic foramen and pudendal canal between the sacrotuberous ligament and the sacrospinal ligament, especially the sciatic spine [23,24]. However, the mechanical injury of the pudendal nerve is often associated with pregnancy, delivery, and pelvic surgery. ...
Pudendal neuralgia (PN) is a complex disease with various clinical characteristics, and there is no treatment showing definite effectiveness. This study is aimed at evaluating the clinical efficacy of ultrasound-guided high-voltage long-duration pulsed radiofrequency (PRF) for PN. Two cadavers (one male, one female) were dissected to provide evidence for localization of the pudendal nerve. Patients diagnosed as PN who failed or were intolerant in regular medication were screened for diagnostic local anesthesia block of the pudendal nerve before recruitment. Twenty PN patients were enrolled in this study. In the PRF procedure, the needle tip was inserted medially into the internal pudendal artery under ultrasound guidance. The position of the PRF needle tip was then adjusted by the response of the pudendal nerve to the electrical stimulation within the pudendal area (42°C, a series of 2 Hz, and 20 ms width pulses that lasted for 900 s). Alleviation of pain was assessed by the visual analogue scale (VAS) and sitting time pretreatment and on 7 d, 14 d, 1 m, 2 m, 3 m, and 6 m posttreatment in outpatient follow-up or by telephone interview. Two patients were lost due to intervention-irrelevant reasons. Patients showed significantly decreased VAS scores on 7 d after RFP, compared with pretreatment status (7.0 ± 0.9 vs. 3.2 ± 1.7, P < 0.001). The efficacy remained steady till the end of 6 months, with a final remission rate of 88.9%. Sitting time also significantly lengthened following PRF (7 d, 14 d, 1 m, 2 m, 3 m, and 6 m vs. pretreatment, all P < 0.05). Only short-term ipsilateral involuntary convulsion of the lower extremity was reported in one patient, who recovered within 12 h. Six patients were treated with nonsteroidal drugs for a short time. All patients stopped taking medication finally. In conclusion, the ultrasound-guided high-voltage long-duration PRF approach not only reduced the pelvic pain caused by PN but also improved the quality of life by extending sitting time without nerve injury.
Some of the most challenging symptomatologies encountered by the nerve surgeon are gluteal, pelvic, perineal, or genital pain. Part of the problem is the difficulty of diagnosis, and part is unfamiliarity with the anatomy of the area. These render the surgeon uncomfortable making the diagnosis or offering treatment. These patients are miserable, lose quality of life, and remain undiagnosed for years. This chapter aims at shedding light on the diagnosis and treatment of these relatively rare pathologies.
Background
The diagnosis of neuromuscular pelvic pain is challenging. Despite the increasing use of magnetic resonance imaging (MRI) in the assessment of pudendal neuralgia, there are limited data describing radiological variations of the nerve. Additionally, the utility of MRI in the assessment of pelvic floor tension myalgia is unknown.
Aims
To describe the anatomical variations of the pudendal nerve and dimensions of pelvic muscles in patients investigated for neuromuscular pelvic pain using a combined MRI protocol.
Materials and methods
A retrospective audit of MRI reports for 136 patients referred to a single radiologist was conducted. Reported data included the appearances of the pudendal nerve and its perineural structures, and the maximal thicknesses of pelvic muscles.
Results
Several anatomical variations were identified in the course of the pudendal nerve at or above the ischial spine. Likely/highly likely nerve compression at this level was present in 34.6% of hemipelves. Variations associated with compression included delayed separation of the sacrospinous and sacrotuberous ligaments ( p < 0.0001), close apposition of ligaments ( p < 0.0001), interligamentous bands ( p = 0.033), coccygeal muscle contributions to the sacrospinous ligament ( p = 0.014) and proximal ( p < 0.0001) and thickened falciform ligaments ( p < 0.0001). Variations below the ischial spine were uncommon.
Conclusions
This study represents a quantitative and qualitative expansion to the radioanatomical basis of pudendal nerve entrapment on MRI, and highlights the limitations of MRI obtaining reproducible measurements of pelvic muscles. Images from asymptomatic controls and further prospective evaluation of treatment outcomes is required to determine the clinical significance of MRI findings in the assessment of pudendal neuralgia.
Pudendal neuralgia is chronic pelvic pain associated with the pudendal nerve. Unfortunately, the best treatment approach is unknown. Our objective was to systematically assess interventions for pudendal neuralgia for improvement in pain.
Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses, we retrieved studies from MEDLINE, EMBASE, and clinicaltrials.gov through May 27, 2024. Our population included patients with pudendal neuralgia. Our interventions included surgery (decompression and nerve stimulation), injections and pulse radiofrequency treatments. Outcomes included improvement in pain (usually on a visual analog scale (VAS)) and adverse events. GRADE criteria were used to assess quality. Differences between pre- and post-intervention pain scores were compared with a random effects REML model and reported as mean difference and 95% confidence intervals.
Six hundred eighty-seven abstracts were screened yielding 37 studies that met eligibility criteria. Treatments included 16 surgeries with 12 nerve decompressions and 4 nerve stimulator placements, 14 injections, and 7 pulse radiofrequency treatments. The majority, 95%, were Grade C. All treatments appear to provide relief to a similar extent (mean difference in VAS of 2.73 cm (1.77, 3.69), p < 0.07, with high heterogeneity I2 = 98.18%), but no treatment was clearly superior for pain relief. Adverse events were inconsistently reported but more severe in the surgery group.
There are many treatment approaches to pudendal neuralgia, but overall, the evidence includes heterogeneous patient populations, non-standardized treatments, poor-quality studies, variable pain measurement instruments, and short-term follow-up. All interventions improved pain with no statistically significant difference between groups.
Pain in the anorectal and pelvic area is a frequent occurrence. In cases in which diagnostic measures do not reveal any overt pathologies, possible differential diagnoses include the levator ani syndrome (LAS), so-called unspecific anorectal pain and pudendal neuropathy (PN). The LAS is characterized by recurrent dull pain each lasting longer than 30 min. A typical clinical finding important for the diagnosis is tenderness of the levator muscle, which can be triggered by digital rectal examination. In the absence of tenderness it is more likely to be unspecific anorectal pain. Biofeedback therapy should be the main treatment approach. The diagnosis of PN is made according to the Nantes criteria, with the positive effect of a pudendal nerve block being an essential criterion. For treatment, surgical neurolysis of the pudendal nerve has the highest probability of achieving long-term pain relief and cessation.
Pain in the anorectal and pelvic area is a frequent occurrence. In cases in which diagnostic measures do not reveal any overt pathologies, possible differential diagnoses include the levator ani syndrome (LAS), so-called unspecific anorectal pain and pudendal neuropathy (PN). The LAS is characterized by recurrent dull pain each lasting longer than 30 min. A typical clinical finding important for the diagnosis is tenderness of the levator muscle, which can be triggered by digital rectal examination. In the absence of tenderness it is more likely to be unspecific anorectal pain. Biofeedback therapy should be the main treatment approach. The diagnosis of PN is made according to the Nantes criteria, with the positive effect of a pudendal nerve block being an essential criterion. For treatment, surgical neurolysis of the pudendal nerve has the highest probability of achieving long-term pain relief and cessation.
The skin and the nervous system interact in physiological responses and pathological disorders including neuropathic pruritus, nerve entrapment syndromes and complex regional pain syndrome. Many genetic neurocutaneous disorders are reported. A skin biopsy can be an aid to the diagnosis of neurological disease and neuropathies.
Aim:
Pudendal and inferior cluneal nerve entrapment can cause a neuropathic pain syndrome in the sensitive areas innervated by these nerves. Diagnosis is challenging and patients often suffer several years before diagnosis is made. The purpose of the review was to inform healthcare workers about this disease and to provide a basis of anatomy and physiopathology, to inform about diagnostic tools and invasive or non-invasive treatment modalities and outcome.
Methods:
A description of pudendal and inferior cluneal nerve anatomy is given. Physiopathology for entrapment is explained. Diagnostic criteria are described, and all non-invasive and invasive treatment options are discussed.
Results:
The Nantes criteria offer a solid basis for diagnosing this rare condition. Treatment should be offered in a pluri-disciplinary setting and consists of avoidance of painful stimuli, physiotherapy, psychotherapy, pharmacological treatment led by tricyclic antidepressants and anticonvulsants. Nerve blocks are efficient at short term and serve mainly as a diagnostic tool. Pulsed radiofrequency (PRF) is described as a successful treatment option for pudendal neuralgia in patients non-responding to non-invasive treatment. If all other treatments fail, surgery can be offered. Different surgical procedures exist but only the open transgluteal approach has proven its efficacy compared to medical treatment. The minimal-invasive ENTRAMI technique offers the possibility to combine nerve release with pudendal neuromodulation.
Conclusions:
Pudendal and inferior cluneal nerve entrapment syndrome are a challenge not only for diagnosis but also for treatment. Different non-invasive and invasive treatment options exist and should be offered in a pluri-disciplinary setting.
Résumé
Souvent présentée comme une spécialité à part entière en algologie, la douleur pelvi-périnéale reste une douleur chronique, bien qu’ayant certaines caractéristiques cliniques propres à elle-même. On pourra la décomposer en plusieurs items cliniques : la composante neuropathique, la participation musculaire, les douleurs ostéo-articulaires, les phénomènes de sensibilisation et les aspects psycho-émotionnels. La prise en charge sera donc, à la fois, très simple et très complexe, puisque chacune de ces composantes va s’exprimer à des degrés différents pour chaque patient. Il n’y aura donc autant de possibilités d’approches thérapeutiques que de patients rencontrés en consultation.
Aim:
pudendal neuralgia is a highly disabling entity with complex diagnostic and controversial treatment results. Surgical neurolysis has been shown to be the most effective treatment. Sacral root neurostimulation or posterior tibial nerve stimulation are used to rescue patients who either have not responded to surgery or have worsened after an initial improvement.
Methods:
given the excellent visualization of the pudendal nerve during laparoscopic pudendal release, the authors propose to combine this procedure with neurostimulation, taking advantage of the possibility of in situ placement of the electrode. Abdominal cavity is accessed laparoscopically through 4 ports and, after identifying and releasing the pudendal nerve, a neurostimulation electrode is placed next to the nerve that is connected to a generator located in a subcutaneous pocket RESULTS: this procedure has been performed in one patient with a satisfactory result.
Conclusions:
laparoscopic pudendal release with neurostimulator prosthesis is an experimental technique that can be promising for the treatment of pudendal neuralgia.
Background
Neurosurgical randomized controlled trials (RCTs) are difficult to carry out due to the low incidence of certain diseases, heterogeneous disease phenotypes, and ethical issues. This results in a weak evidence base in terms of both the number of trials and their robustness. The fragility index (FI) measures the robustness of an RCT and is the minimum number of patients in a trial whose status would have to change from a nonevent to an event to change a statistically significant result to a nonsignificant result. The smaller the FI, the more fragile the trial's outcome.
Methods
RCTs that have influenced neurosurgical practice were included in this analysis. Simulations were run to calculate the FI. To determine associations with a high or low FI, multivariable logistic regression was used to calculate adjusted odds ratios and 95% confidence intervals adjusting for baseline confounders.
Results
Of 2975 papers screened, 74 were included. The median FI was 4.5 (interquartile range: 1.5–10). RCTs included a median of 165 patients (interquartile range: 75–330), with a maximum of 10,008. A total of 38 trials had lost to follow-up patients that might have impacted the robustness of the results (51%).
Conclusion
Results of neurosurgical RCTs on which we base our clinical decision-making and treatment guidelines are often fragile. Improved methodologies, international collaboration, and cooperation between specialties might improve the evidence base in the future.
Background
Patients with intractable pain in the pudendal nerve distribution may benefit from pudendal neuromodulation; however, some may have previously undergone pudendal nerve entrapment surgery (PNES), potentially altering nerve anatomy and function.
Aim
We examined pudendal neuromodulation outcomes in patients with prior PNES.
Methods
Patients with a history of PNES and quadripolar, tined pudendal lead placement for urogenital pain were reviewed. Symptoms and outcomes were collected from existing medical records.
Outcomes
Patients with pudendal neuromodulation and prior PNES were compared to patients with no prior PNES who had pudendal lead placement.
Results
Fifteen patients with a history of 1, 2, or 3 prior PNES (n = 13, 1, and 1, respectively) were evaluated. Most (10; 67%) were female, with bilateral pain (9; 60%), and symptoms of 5–26 years. After trialing the lead, bladder symptoms and pain were improved in 8 of 12 and 9 of 14 patients, respectively, and 80% of patients (12/15) underwent permanent generator implantation. When prior PNES patients were compared to those with no prior PNES (n = 43), gender (67% vs 77% female; P = .50) and age (median 63 vs 58 years; P = .80), were similar; however, BMI differed (mean 24 vs 29; P = .008) and a lower proportion (12/15; 80% vs 42/43; 98%; P = .049) had generator implantation. Importantly, median lead implant time (48 vs 50 minutes; P = .65) did not differ between the 2 groups.
Clinical Implications
Pudendal neuromodulation has the potential to provide pain relief for a very difficult-to-treat population; furthermore, it does not appear that prior PNES surgery made lead placement significantly more challenging.
Strengths & Limitations
Study strengths include being a tertiary referral center for urogenital pain and having a single surgeon perform all procedures in a regimented way. Limitations include the retrospective study design, small sample size and various approaches to PN
Conclusion
Chronic pudendal neuromodulation can be a viable option even after prior PNES.
Kristen M. Meier, Patrick M. Vecellio, Kim A. Killinger, Judith A. Boura, Kenneth M. Peters. Pudendal Neuromodulation is Feasible and Effective After Pudendal Nerve Entrapment Surgery. J Sex Med 2022;XX:XXX–XXX.
Although rarely requiring surgery, irritable bowel syndrome (IBS), chronic abdominal pain, and chronic pelvic pain are a sizeable subset of patients referred to a colorectal specialist. This group of patients suffer from frequent misdiagnoses and are at increased likelihood of undergoing inappropriate surgical procedures. Having a rational diagnostic and treatment approach will ensure appropriate surgical referrals and improved quality of life for patients.
Objective: Some articles have reported the surgical management of Alcock canal syndrome (ACS) using transperineal [1], transgluteal [2], or conventional laparoscopic approach [3, 4]. In 2015, Rey and Oderda reported the first robotic neurolysis of the pudendum, providing the advantages of robot-assisted surgery: magnified and 3-dimensional vision and greater precision of movements [5]. However, to our knowledge, there have been no reports of the use of a robotic platform for the treatment of ACS in the field of gynecology. Therefore, the objective of this video is to describe the anatomic and technical highlights of robotic exploration of the somatic nerves in the pelvis and transection of the sacrospinous ligament (nerve decompression) for ACS.
Design: Stepwise demonstration of the technique with narrated video footage.
Setting: An urban general hospital. A 48-year-old woman who had no previous surgical history was referred for severe sitting pain, cyclic pelvic pain, gluteal and perineal pain, all of which were resistant to medication therapy. Her pain radiated to the posterior aspect of the thigh. Before coming to our hospital, she visited an orthopedic surgeon a few years earlier and was diagnosed with sciatic neuralgia. MRI revealed adenomyosis with neither deep endometriosis nor vascular entrapment. Based on neuropelveological evaluation, the patient was suspected to be suffering from ACS due to compression of the pudendal nerve and the posterior cutaneous nerve of the thigh by the sacrospinous ligament.
Interventions: The procedure was performed using the following 9 steps while referencing laparoscopic neuro-navigation (LANN) technique [6]: Step 1, opening the peritoneum along external iliac artery; Step 2, exposure of the external iliac artery; Step 3, development of the lumbosacral space; Step 4, identification of the lumbosacral trunk; Step 5, identification of the superior gluteal nerve; Step 6, identification of the sciatic nerve; Step 7, identification of the inferior gluteal nerve; Step 8, identification of the pudendal nerve; and Step 9, transection of the sacrospinous ligament. The surgery was successfully completed without any complications and the postoperative course was uneventful. We considered that there was no relationship between the ACS and the endometriosis. The patient reported that her pain decreased gradually at postoperative 1st and 3rd months, and finally the neuralgia was completely resolved at the 6th month. Neuropelveological evaluation still continues every 6 months.
Conclusion: Robot-assisted transection of the sacrospinous ligament is feasible, safe technique for selected patients with ACS. Exploration of the pelvic nerves should be performed for further diagnosis and therapy before prematurely labeling the patient as refractory to the treatment [7].
Aims
In patients with pudendal neuralgia, prior studies have shown efficacy in chronic stimulation with Interstim® (Medtronic, Inc.). This feasibility study reports on the initial experience of using a wireless system to power an implanted lead at the pudendal nerve, StimWave®, to treat pudendal neuralgia.
Methods
Retrospective chart review identified patients with a lead placed at the pudendal nerve for neuralgia and powered wirelessly. Clinical outcomes were assessed at Postoperative visits and phone calls. Administered non-validated follow-up questionnaire evaluated the Global Response Assessment, percentage of pain improvement, satisfaction with device, and initial and current settings of the device (h/day of stimulation).
Results
Thirteen patients had the StimWave® lead placed at the pudendal nerve, 12 (92%) female and 1 (7.6%) male. Mean age was 50 years (range: 20–58). Failed prior therapies include medical therapy (100%), pelvic floor physical therapy (92%), pudendal nerve blocks (85%), pelvic floor muscle trigger point injections (69%), neuromodulation (30.7%), or surgeries for urogenital pain (23.1%). After the trial period, 10/13 (76.9%) had >50% improvement in pain with 6/13 (46.1%) reporting 100% pain improvement. Nine underwent permanent lead placement. At last postoperative visit (range, 6–83 days), 5/9 patients reported >50% pain improvement. Seven patients reached for phone calls (22–759 days) reported symptoms to be “markedly improved” (n = 2), “moderately improved” (n = 4), or “slightly improved” (n = 1). At follow up, complications included lead migration (n = 2), broken wire (n = 1), or nonfunctioning antenna (n = 2).
Conclusion
Complex patients with pudendal neuralgia may benefit from pudendal nerve stimulation via StimWave®.
Pudendal nerve entrapment syndrome is widely unknown and often misdiagnosed or confused with other pelvic floor diseases. The aim is to develop a diagnostic and therapeutic algorithm based on a review of the existing literature. For its diagnosis, an anamnesis will be carried out in search of possible aetiologies, surgical history, and history of pain, assessing location and irradiation, intensity on the visual analogue scale, timing, triggering factors and rule out alarm signs. A physical examination will be performed, looking for trigger points or areas of fibrosis with transvaginal/transrectal palpation of the terminal branches of the nerve. With a doubtful diagnosis, an anaesthetic block of the pudendal nerve can be performed. Once the diagnosis is confirmed, the treatment will begin staggered with lifestyle changes, drug therapy and physiotherapy. In view of the failure of these measures, invasive therapies such as botulinum toxin injection, pulsed radiofrequency and decompression surgery or spinal cord stimulation will be used.
Background
Placebo treatments have been reported to help patients with many diseases, but the quality of the evidence supporting this finding has not been rigorously evaluated.
Methods
We conducted a systematic review of clinical trials in which patients were randomly assigned to either placebo or no treatment. A placebo could be pharmacologic (e.g., a tablet), physical (e.g., a manipulation), or psychological (e.g., a conversation).
Results
We identified 130 trials that met our inclusion criteria. After the exclusion of 16 trials without relevant data on outcomes, there were 32 with binary outcomes (involving 3795 patients, with a median of 51 patients per trial) and 82 with continuous outcomes (involving 4730 patients, with a median of 27 patients per trial). As compared with no treatment, placebo had no significant effect on binary outcomes, regardless of whether these outcomes were subjective or objective. For the trials with continuous outcomes, placebo had a beneficial effect, but the effect decreased with increasing sample size, indicating a possible bias related to the effects of small trials. The pooled standardized mean difference was significant for the trials with subjective outcomes but not for those with objective outcomes. In 27 trials involving the treatment of pain, placebo had a beneficial effect, as indicated by a reduction in the intensity of pain of 6.5 mm on a 100-mm visual-analogue scale.
Conclusions
We found little evidence in general that placebos had powerful clinical effects. Although placebos had no significant effects on objective or binary outcomes, they had possible small benefits in studies with continuous subjective outcomes and for the treatment of pain. Outside the setting of clinical trials, there is no justification for the use of placebos.
One hundred patients, referred for the management of intractable pain, completed a 52-item Illness Behaviour Questionnaire (IBQ). Responses were scored on 7 scales: General hypochondriasis, disease conviction, psychological versus somatic perception of illness, affective inhibition, affective disturbance, denial and irritability. IBQ scale profiles were used to study the relationship between chronicity of pain and pattern of illness behaviour reported. Except in the case of one scale, no significant correlation emerged. This overall lack of association between chronicity and illness behaviour remained even when the patient sample was restricted to those 20 patients having substantial organic pathology associated with their pain. These findings suggest that degree of chronicity is unlikely to play a major role in determining the illness behaviour manifested by patients with intractable pain.
Certaines douleurs périnéales chroniques peuvent être rapportées à une souffrance des nerfs honteux internes (NHI): la constance
de la symptomatologie clinique d'un patient à l'autre et au cours du temps chez un même patient, les altérations révélées
par les études électro-physiologiques, la positivité des blocs diagnostiques, les données de l'étude anatomique réalisée,
les résultats préliminaires des thérapeutiques médicale et chirurgicale mises en œuvre apportent des arguments convergents
en faveur d'une possible atteinte organique des NHI.
A number of chronic pain syndroms in the perineal aerea can be related to pudental nerves suffering. The constancy of symptoms
among various patients, and in duration for a particular one, alterations revealed by electrophysiologic studies, pain relief
by diagnostic blocks, data from anatomic studies, preliminary results of medical and surgical applied therapies, give consistent
arguments for possible organic lesions of pudental nerves.
Of the different types of visual analogue and graphic rating scales tested in a series of experiments, only two were satisfactory: these were the visual analogue scale and the graphic rating scales used horizontally with the words spread out along the whole length of the line. Other types of scale used gave distributions of results which were not uniform. Unusual distribution of results occurred when patients selected a position adjacent either to descriptive terms or preferred numbers. In some experiments, the distribution of results was determined by the nature of the experiment. Alternation of the ends of a scale did not affect the results. The behaviour of the graphic rating scale was different in patients accustomed to completing it and in those not so accustomed.The results of pain severity measured by these methods showed a very good correlation with pain severity measured by the simple descriptive pain scale. Changes in visual analogue scores also correlated well with changes in simple descriptive pain scores. The visual analogue and graphic rating scales were more sensitive than the traditional simple descriptive pain scale. Most patients could readily use visual analogue and graphic rating scales despite having no previous experience. The failure rate was slightly lower with the graphic rating method. Use of these scales is the best available method for measuring pain or pain relief.
A step-by-step analysis of Beck's and Hamilton's rating scales showed that both scales failed to differentiate adequately between moderate and severe depression measured by a global clinical assessment. Each item of the scales was tested for calibration, ascending monotonicity, and dispersion parallel to the clinical assessment. Twelve items of Beck's scale and six items of Hamilton's scale were found valid with respect to these criteria. Those items should be taken into account in future research for baseline ratings and for change ratings of depressive states quantitatively.
We call attention to a group of patients with chronic vulvar burning (vulvodynia), who do not have apparent infections or easily discernible abnormal physical findings, but who on simple sensory testing have allodynia, hyperalgesia, hyperpathia, and hypoesthesia in varying permutations within the areas innervated by the pudendal nerve. We propose that pudendal neuralgia (pain along the pudendal nerve) is one of the causes of idiopathic vulvodynia. In those patients in whom a neurologic, metabolic, infectious, traumatic, or malignant cause for neuralgia is not found, medical management with tricyclic antidepressants, antiepileptic agents, or both may prove helpful. Awareness of this entity will lead to earlier diagnosis, treatment, and reassurance of patients with chronic vulvar burning.
The anatomic study of the pudendal nerve and its relation allows an approach of the mechanisms of compression likely to engender perineal neuralgia. Two conflictual zones are isolated: the first is linked to the clamp which is produced by the insertion of the sacro-epinous ligament on the ischial spine and the sacro-tuberal ligament; the second is linked to the falciform process of the sacrotuberal which threatens the nerve by its sharp upper edge. This conflict is particularly acute in a sitting position. The relation between the trunk of the nerve, its branches and these zones of conflict may explain the clinical observations. The electrophysiological investigations (detection of neurogenic muscles of the perineal floor. Increased sacral latency, pudendal nerve terminal motor latency) confirm the diagnosis. The anesthetic blocks of the pudendal nerve on the ischial spine only have a complimentary diagnostic value. The peridural blocks may also have an interesting therapeutic action (60% of good results 3 months later). In some persistent cases, the nerve has been decompressed firstly by perineal approach, but latterly by transguteal approach.
Clinical observations in patients suffering from positional perineal pain have led us to performing an anatomical study of the pudendal nerve in order to demonstrate compression of this nerve trunk by elements likely to compress it in the sitting position. Thus we observed that the falciform process of the sacrotuberous ligament may act in this way. Besides helping us to understand the clinical symptoms, this anatomical study allowed choosing the technique we found most appropriate for the anatomical conditions observed out of the various neurophysiological examinations described in the literature. Lastly, we describe the surgical technique that allows releasing the trunk of the pudendal nerve under an operating microscope.
Fifteen cases of perineal neuralgia are reviewed, the lesion arising from a canal syndrome due to compression of the pudendal nerve in the ischiorectal fossa (Alcock's canal syndrome). The clinical characteristic of the pain syndrome was its postural nature with the existence of a true Tinel sign (increased pain on sitting). Diagnosis was confirmed in all cases by a perineal electrophysiological which showed peripheral neurogenic signs on examination of perineal muscles and an increase in sacral evoked potentials latencies (latency of bulbocavernous or clitorido-anal reflexes, cortical somesthetic evoked potential from pudendal nerve). Treatment was infiltration of cortisone derivatives into the pudendal nerve canal, under CT guidance because of the difficulty of infiltrating the pudendal nerve by an external perineal approach. Results were satisfactory in 9 of the 15 patients.
A number of chronic pain syndromes in the perineal area can be related to pudendal nerves suffering. The constancy of symptoms among various patients, and in duration for a particular one, alterations revealed by electrophysiologic studies, pain relief by diagnostic blocks, data from anatomic studies, preliminary results of medical and surgical applied therapies, give consistent arguments for possible organic lesions of pudendal nerves.
Pain syndromes of the urogenital and rectal area are well described but poorly understood and underrecognized focal pain syndromes. They include vulvodynia, orchialgia, urethral syndrome, penile pain, prostatodynia, coccygodynia, perineal pain, proctodynia and proctalgia fugax. The etiology of these focal pain syndromes is not known. A specific secondary cause can be identified in a minority of patients, but most often the examination and work-up remain unrevealing. Although these patients are often depressed, rarely are these pain syndromes the only manifestation of a psychiatric disease. This review article presents an overview of the neuroanatomy of the pelvis, which is a prerequisite to trying to understand the chronic pain syndromes in this region. We then discuss the clinical presentation, etiology and differential diagnosis of chronic pain syndromes of the urogenital and rectal area and review treatment options. The current knowledge of the psychological aspects of these pain syndromes is reviewed. Patients presenting with these pain syndromes are best assessed and treated using a multidisciplinary approach. Currently available treatment options are empirical only. Although cures are uncommon, some pain relief can be provided to almost all patients using a multidisciplinary approach including pain medications, local treatment regimens, physical therapy and psychological support, while exercising caution toward invasive and irreversible therapeutic procedures. Better knowledge of the underlying pathophysioloigical mechanisms of the urogenital and rectal pain syndromes is needed to allow investigators to develop treatment strategies, specifically targeted against the pathophysiological mechanism.
Our anatomic findings have led us to define conflictual relations that may be encountered in their course by the pudendal n. and its branches. Starting from the clinical study of a group of patients suffering from chronic perineal pain in the seated position, we have defined, beginning with the cadaver, three possible conflictual settings: in the constriction between the sacrotuberal and sacrospinal ligaments; in the pudendal canal of Alcock; and during the straddling of the falciform process of the sacro-tuberal ligament by the pudendal n. and its branches. Consequently, considering so-called idiopathic perineal pain as an entrapment syndrome, the clinical and neurophysiologic arguments and infiltration tests have led us to define a surgical strategy which has currently given 70% of good results in 170 operated patients. Earlier diagnosis should improve on this.
Notwithstanding many established causes of vulvodynia there still remains an idiopathic group with unknown etiology and variable results of treatment. We present 11 women with idiopathic vulvodynia in whom the etiology could be defined and who were successfully treated. Age varied from 28-53 years. The vulvar pain was associated with stress urinary incontinence in 6/11 patients and all had constipation. Perineal and vulvar hypoesthesia occurred in 6, weak anal reflex in 7 and diminished EMG activity of the external anal sphincter in 3, of the external urethral sphincter in 6 and of the levator ani muscle in 11. There was significant increase (P<0.05) of the pudendal nerve terminal motor latency (PNTML) in all. The motor and sensory change as well as the increased PNTML point to pudendal canal syndrome. Pudendal nerve block, as a diagnostic and therapeutic test, effected temporary pain relief. Pudendal nerve decompression was performed. The inferior rectal nerve was exposed through a para-anal incision, and followed to the pudendal nerve in the pudendal canal. Pudendal canal fasciotomy was done to release the pudendal nerve in the ischiorectal fossa. Vulvar pain disappeared in 9/11 women and stress urinary incontinence in 4/6. Anal reflex was normalized in 5/7 women, and vulvar and perineal hypoesthesia in 4/6. The EMG activity of the external urethral sphincter improved in 4/6, of the external anal sphincter in 2/3 and of the levator ani in 9/11 women. The PNTML was normalized in 9/11 women. In conclusion, pudendal nerve decompression effected relief and improvement in the sensory and motor manifestations of the pudendal nerve in 9/11 women. Two women did not improve due probably to an irreversible damage of the pudendal nerve, or to incomplete pudendal nerve decompression.
Pelvic floor tension myalgia may contribute to the symptoms of male patients with chronic pelvic pain syndrome (CPPS). Therefore, measures that diminish pelvic floor muscle spasm may improve these symptoms. Based on this hypothesis, we enrolled 19 patients with CPPS in a 12-week program of biofeedback-directed pelvic floor re-education and bladder training.
Pre-treatment and post-treatment symptom assessments included daily voiding logs, American Urological Association (AUA) symptom score, and 10-point visual analog pain and urgency scores. Pressure-flow studies were obtained before treatment in most patients. Instruction in pelvic floor muscle contraction and relaxation was achieved using a noninvasive form of biofeedback at biweekly sessions. Home exercises were combined with a progressive increase in timed-voiding intervals.
Mean age of the 19 patients was 36 years (range 18 to 67). Four patients completed less than three treatment sessions, 5 patients completed three to five sessions, and 10 attended all six sessions. Mean follow-up was 5.8 months. Median AUA symptom scores improved from 15.0 to 7.5 (P = 0.001), and median bother scores decreased from 5.0 to 2.0 (P = 0.001). Median pain scores decreased from 5.0 to 1.0 (P = 0.001), and median urgency scores decreased from 5.0 to 2.0 (P = 0.002). Median voiding interval increased from 0.88 hours to 3.0 hours (P = 0.003). Presence of detrusor instability, hypersensitivity to filling, or bladder-sphincter pseudodyssynergia on pretreatment urodynamic studies was not predictive of treatment results.
This preliminary study confirms that a formalized program of neuromuscular re-education of the pelvic floor muscles together with interval bladder training can provide significant and durable improvement in objective measures of pain, urgency, and frequency in patients with CPPS.
The use of placebo in analgesia, both in research and clinical studies, is a highly controversial issue, but also very common in both areas. The assessment of the actual contribution of placebo in order to maximize analgesic effects can be useful approach in many circumstances.
Les névralgies du nerf pudendal (honteux interne) Considérations anatomo-cliniques et perspectives thérapeutiques Pudendal neuralgia
- Jj Labat
- R Robert
- M Bensignor
- Jm Buzelin
- Ml Turner
- Marinoff
Labat JJ, Robert R, Bensignor M, Buzelin JM. Les névralgies du nerf pudendal (honteux interne). Considérations anatomo-cliniques et perspectives thérapeutiques. J Urol Paris 1990;96:239–44. [3] Turner ML, Marinoff SC. Pudendal neuralgia. Am J Obstet Gynecol 1991;165:1233–6.
Syndrome du canal d’Acock et ne ´vralgie pe ´rine ´ale
- Amarencog
- Lanoey
- Ghnassiart
- Goudalh
AmarencoG,LanoeY,GhnassiaRT,GoudalH,PerrigotM.Syndrome du canal d’Acock et ne ´vralgie pe ´rine ´ale. Rev Neurol Paris 1988;144:523–6.
Re ´flexions cliniques, neurophysiologiques et the ´rapeu-tiques a ` partir de donne ´es anatomiques sur le nerf pudendal(honteux interne) lors de certaines algies pe ´rine ´ales
- R Robert
- Jj Labat
- Pa Lehur
- P Glemain
- Le Armstrong
- J Borgne
- Barbin
Robert R, Labat JJ, Lehur PA, Glemain P, Armstrong O, Le Borgne J, Barbin JY. Re ´flexions cliniques, neurophysiologiques et the ´rapeu-tiques a ` partir de donne ´es anatomiques sur le nerf pudendal(honteux interne) lors de certaines algies pe ´rine ´ales. Chirurgie 1989;115: 515–20.
Les ne ´vralgies du nerf pudendal (honteux interne) Conside ´rations anatomo-cliniques et per-spectives the ´rapeutiques
- Jj Labat
- R Robert
- M Bensignor
- Buzelin
Labat JJ, Robert R, Bensignor M, Buzelin JM. Les ne ´vralgies du nerf pudendal (honteux interne). Conside ´rations anatomo-cliniques et per-spectives the ´rapeutiques. J Urol Paris 1990;96:239–44.
Les né du nerf pudendal (honteux interne) Considé anatomo-cliniques et per-spectives thé
- Labat
- Robert R Jj
- M Bensignor
- Buzelin
- Jm
Labat JJ, Robert R, Bensignor M, Buzelin JM. Les né du nerf pudendal (honteux interne). Considé anatomo-cliniques et per-spectives thé. J Urol Paris 1990;96:239–44.
Ré cliniques, neurophysiologiques et thé a ` partir de donné anatomiques sur le nerf pudendal(honteux interne) lors de certaines algies périné
- Robert R Labat Jj
- Pa Lehur
- Armstrong P O Glemain
- Le J Borgne
- Barbin
- Jy
Robert R, Labat JJ, Lehur PA, Glemain P, Armstrong O, Le Borgne J, Barbin JY. Ré cliniques, neurophysiologiques et thé a ` partir de donné anatomiques sur le nerf pudendal(honteux interne) lors de certaines algies périné. Chirurgie 1989;115:515–20.
Syndrome du canal d'Acock et né périné
- G Amarenco
- Y Lanoe
- H Ghnassia Rt
- Perrigot
Amarenco G, Lanoe Y, Ghnassia RT, Goudal H, Perrigot M. Syndrome du canal d'Acock et né périné. Rev Neurol Paris 1988;144:523–6.
Les névralgies du nerf pudendal (honteux interne). Considérations anatomo-cliniques et perspectives thérapeutiques
- J J Labat
- R Robert
- M Bensignor
- J M Buzelin
Labat JJ, Robert R, Bensignor M, Buzelin JM. Les névralgies du nerf
pudendal (honteux interne). Considérations anatomo-cliniques et perspectives thérapeutiques. J Urol Paris 1990;96:239-44.
- M L Turner
- S C Marinoff
- Pudendal
Turner ML, Marinoff SC. Pudendal neuralgia. Am J Obstet Gynecol
1991;165:1233-6.
Réflexions cliniques, neurophysiologiques et thérapeutiques à partir de données anatomiques sur le nerf pudendal(honteux interne) lors de certaines algies périnéales
- R Robert
- J J Labat
- P A Lehur
- P Glemain
- O Armstrong
- Le Borgne
- J Barbin
Robert R, Labat JJ, Lehur PA, Glemain P, Armstrong O, Le Borgne J,
Barbin JY. Réflexions cliniques, neurophysiologiques et thérapeutiques à partir de données anatomiques sur le nerf pudendal(honteux
interne) lors de certaines algies périnéales. Chirurgie 1989;115:
515-20.
Syndrome du canal d'Acock et névralgie périnéale
- G Amarenco
- Y Lanoe
- R T Ghnassia
- H Goudal
- M Perrigot
Amarenco G, Lanoe Y, Ghnassia RT, Goudal H, Perrigot M. Syndrome
du canal d'Acock et névralgie périnéale. Rev Neurol Paris
1988;144:523-6.
Les névralgies du nerf pudendal (honteux interne). Considérations anatomo-cliniques et perspectives thérapeutiques
- Labat
Réflexions cliniques, neurophysiologiques et thérapeutiques à partir de données anatomiques sur le nerf pudendal(honteux interne) lors de certaines algies périnéales
- Robert
Syndrome du canal d’Acock et névralgie périnéale
- Amarenco