Pudendal Nerve Entrapment....

[Guest guest]

Here's another I found in my 'mess'. Dee

========================================

Pudendal

Neuralgia

Pudendal neuralgia is pain in the area supplied by the

pudendal nerve. This includes the external genitals, the

urethra, the anus, and the perineum.

Fred M. , Jr., M.D., M.S.

Professor of Obstetrics & Gynecology

Department of Obstetrics & Gynecology

University of Rochester Medical Center

601 Elmwood Avenue

Rochester, NY 14642-8668

Telephone:

Per Lennart Westesson, MD, PhD, DDS

Professor of Radiology

Division of Diagnostic and

Interventional Neuroradiology

University of Rochester Medical Center

601 Elmwood Avenue

Rochester, NY 14642-8648

Telephone:

S T R O N G H E A L T H

STRONG MEMORIAL HOSPITAL

For questions regarding clinical appointments, clinical examinations, and clinic visits call Dr. Fred 's office at .

For questions regarding pudendal nerve blocks please call

Dr. P-L Westesson's office at .

Frequently asked questions

1. What is Pudendal Nerve Entrapment?

Pudendal Nerve Entrapment is a pain condition for no apparent

reason in the lower central pelvic areas. These are the anal region,

perineum, and scrotum and penis or vulva.

Pain is worse upon sitting and less when standing or sitting on a

donut cushion or toilet seat.

The pain could be stinging, burning, stabbing, aching,

Knife-like, irritation, cramping, spasm, tightness, crawling on the

skin, twisting, pins and needles, numbness, and hyper sensitivity.

The pain is piercing and very comparable to a toothache. It often

starts in one place and progresses. Frequently there is also urinary,

anal, or sexual dysfunction. The pain is often on both sides.

2. What causes pudendal nerve entrapment?

Pudendal nerve entrapment is caused by entrapment of the

pudendal nerve. The initial constriction is often caused by

pressure or trauma. As the nerve swells it encounters a natural

constraint. Stretching or rubbing of the pudendal nerve can also

cause pudendal nerve entrapment.

3. What causes entrapment?

Pudendal nerve entrapment is usually precipitated by prolonged

sitting or trauma to the sitting area, combined with a

genetic and developmental susceptibility.

Pudendal nerve entrapment is common in high mileage (drivers) and

it is sometimes called Cyclist’s Syndrome.

4. What is Pudendal nerve entrapment frequently misdiagnosed

as?

Prostatodynia, nonbacterial prostatitis, idiopathic vulvodynia

(Idiopathic means unknown cause, dt), idiopathic orchialgia, idiopathic

proctalgia, idiopathic penile pain syndrome etc.

5. What are the most common symptoms of PNE?

The main symptom is pain with sitting. You feel great in the

AM until you sit for coffee, or drive to work. You get better with

lying down. The pain is in the distribution of the pudendal nerve....

genitalia, perineal or rectal. It can be any combination of these

areas depending on the part of the nerve entrapped.

6. What are the treatment options?

1. Avoiding the offending factor that causes pain

2. Three sequential image guided nerve blocks first with local

anesthetics and later possible combined with corticosteroids

3. Conservative medical treatment such as neurotin, Elavil

4. Surgery with decompression of the nerves is rarely done

7. If a patient suspects that they have pudendal neuralgia what

should they do to get help?

First, you need to make sure that other possible conditions

are ruled out. It is important to have a complete workup. Next is

an image guided nerve block and if you get numb in the area of

your pain and pain is gone you have a good indication that you

might have pudendal neuralgia.

8. Is there a connection between pudendal neuralgia and spinal

disorders and scoliosis?

No.

9. Which CPT codes are applicable for the image guided nerve

block?

64430 Injection, anesthetic agent; pudendal nerve

76360 Computed tomography guidance for needle placement

(e.g., biopsy, aspiration, injection, localization device),

radiological supervision and interpretation

Symptoms of Pudendal Neuralgia

Pudendal neuralgia is frequently caused by a mechanical and/or

inflammatory damage to this nerve. Symptoms include vague pains,

stabbing pains, burning sensations, pin pricking, numbness, twisting,

cold sensations and pulling sensations.

The area involved could be the rectum, anus, urethra, and perineum. In women, the vagina and vulva, the vaginal entrance, the minor and major labia, the mons veneris, and the clitoris.

In men, the penis and scrotum may be similarly affected. Pains and paraesthesias symptoms may extend as far as the groin, inner leg, buttocks, and abdomen.

The pain and paraesthesia may be perceived in only one of these areas, in several, or in all of them. These symptoms may be unilateral or bilateral or more distinct on one side than the other, and they are usually exacerbated by sitting position.

Utilization of a “doughnut” pillow and/or sitting on a toilet seat often provides some degree of comfort, as this lessens the pressure on the pudendal nerve(s). The skin overlying some of this region may react with extreme sensitivity to the slightest touch (hyperesthesia and allodynia), such that the affected person may avoid wearing certain items of clothing to avoid such discomfort.

Difficulty with normal voiding, with hesitancy or extreme urgency may cause repeated trips to the bathroom.

Bowel function may be abnormal, as well as painful.

Constipation is reported more frequently among those individuals diagnosed with pudendal neuralgia. Sexual intercourse may be problematic as penetration, for the woman, may be extremely painful, and for the males erectile dysfunction and/or pain with orgasm may predominate.

DIFFERENTIAL DIAGNOSIS

There are many other causes for similar symptoms and other

underlying conditions such as tumors, diseases of the spine or skin,

gynecological, urological, and/or proctological conditions should be

excluded before concluding that the patient suffer from pudendal neuralgia.

Specifically chronic or non-bacterial prostatitis, prostatodynia,

vulvodynia, vestibulitis, chronic pelvic pain syndrome, proctalgia,

anorectal neuralgia, pelvic contracture syndrome/pelvic congestion

or levator ani syndrome can resemble pudendal neuralgia.

Pain in the genital region is often brushed aside as a “psychosomatic” which leaves the patient feeling more distressed, uncertain, and helpless.

The pudendal nerve comes from the sacral plexus (S2-S4) and

enters the gluteal region through the lower part of the greater sciatic

foramen. It courses through the pelvis around ischial spine and

between the sacrospinous and sacrotuberous ligaments. It splits up

into the rectal/anal, perineal and clitorial/penis branches.

The nerve turns forward and downwards through the lower

sciatic foramen underneath the surface of the levator muscle into

the Alcock's canal where the nerve is flattened out between this

double fascia (aponeurosis). The two most important narrow passages are around the ischial spine between the sacrospinous and

the sacrotuberous ligament (80%), and in the Alcock’s canal (20%).

Cycling, riding and long drives can kick off the symptoms of pudendal

neuralgia.

DIAGNOSIS

Pudendal neuralgia is a diagnosis of exclusion meaning that other causes for the symptoms must be excluded before the diagnosis of pudendal neuralgia is made.

Image guided pudendal nerve block

Image guided pudendal nerve block is the most important diagnostic test following history and physical examination.

The nerve is blocked by local anesthetic to see if symptoms can be eliminated by numbing the nerve. The block is done where the nerve is passing between the two ligaments or in the Alcock’s canal. In the first case, the block would be administered through the buttock into the area adjacent to the ischial tuberosity. In the second

case, the block is given directly into the Alcock’s canal.

Pudendal Nerve Motor Latency Test

Pudendal Nerve Motor Latency Test is similar to EMG (electromyogram) and measures the speed of nerve conduction. Electrodes fixed in the muscles of the perineum, in the rectum, in the muscles underneath the vulva around the vaginal entrance and the pudendal nerve is stimulated electrically while measuring the speed of the stimulus transmission. This speed is often slower when the nerve is compressed. This test is done relatively infrequently and has been replaced by image guided pudendal nerve blocks.

Pudendal nerve block and steroid injection

Image guided anesthetic and steroid blocks of the pudendal nerve

are used for both diagnosis and treatment. If the pain is relieved immediately following the block it suggests that the pudendal nerve is

the source of the symptoms and is probably trapped.

Symptoms often return as the local anesthetics wears off.

The steroids may or may not relieve symptoms for a longer period of time. If they do, it usually begins to improve about two weeks after the block, with improvements continuing for up to four to five weeks. Two to three blocks may be sufficient, alone, to cure the problem.

The purpose of the steroid is to reduce inflammation and allow the nerve more room to glide freely. After the injection, there might be a temporary deterioration due to

the steroid for a period of two to ten days (worsening of symptoms).

The blocks are done at the at the ischial spine between the sacrospinous and sacrotuberous ligaments or in the area of Alcock’s canal.

Botox (botulinum toxin) injections have been proposed but there

is no documentation as to its effect.

One injection protocol is to administer three sets of injections 1 weeks apart; the first injection is local anesthetics and if this has a positive effect the next two injections is a mixture of methylprednisolone (1 mL of 40 mg/mL solution) and bupivacaine (3 mL of 0.25% solution). The injections are usually given at the level of the ischial spine but if not successful the injection can be given directly into the pudendal canal (Alcock’s canal).

Usually the injections are unilateral, but patients with bilateral symptoms, both sides may be injected.

Medical Management

Medical management may include an anti-depressant and/or an

anti-seizure medication.

Surgery

Surgery is rarely done for this condition. The results are not well

documented and the operations are only available in a handful places

in France and US. If there is temporary or partial improvement after

the injections and if the nerve is still suspected of being compressed

some Doctors believe that decompression of the nerve through surgery may be an alternative for selected patients.

The nerve is exposed and freed from any entrapment or constriction along its entire course. The surgery is done under general anesthesia and lasts approximately 20-30 minutes per side. After the surgery, it takes a few to several months before a successful outcome can be demonstrated, as the nerve requires a relatively long period of time to heal. Often post surgical injections are needed. Surgery has been reported to be 60% successful, but there are no scientific studies published.

REFERENCES:

.. FM, The role of laparoscopy in the evaluation of chronic

pelvic pain: pitfalls with a negative laparoscopy. J Am Assoc

Gynecol Laparosc 1996; 4:1,85-94.

• FM. Adhesiolysis for pain relief. Operative Techniques

in Gynecologic Surgery 2000;5:3-12.

• FM. Chronic Pelvic Pain in Women. Amer J Managed

Care 2001;7:1001-13.

• FM. Gynecologic Pain. In: Handbook of Pain Management,

3rd Edition. CD Tollison, JR Satterthwaite, JW Tollison,

eds. Lippincott, , and Wilkins: Philadelphia, 2001, pp

459-93.

• FM. Laparoscopic evaluation and treatment of women

with chronic pelvic pain. J Am Assoc Gynecol Laparosc

1994;1:325-31.

• FM. The role of laparoscopy as a diagnostic tool in

chronic pelvic pain. Bailliere’s Best Practice & Research in

Clinical Obstetrics & Gynaecology 2000;14:467-94.

• FM. The role of laparoscopy in chronic pelvic pain:

promise and pitfalls. Obstet Gynecol Survey 1993;48:357-87.

• http:/pn.jcon.org

• http:/pudendal.de/

• http:/pudendal.de/Publikationen/CTARTICLE.pdf

• http:/pudendal.info/

• http:/pudendal.info//info/documents/

• http:/pudendal.info/documents/CT_GuidedNerveBlock.pdf

• http:/pudendal.info/info/documetns/IschialSpineAndPNE.pdf

• http://www.pudendal.de/Publikationen/Anal%20pain%20caus

ed%20bei%20Nervus%20Pudendus%20(Shafik).pdf

• Mc JS, Spigos DG. Computed tomography-guided

pudendal block for treatment of pelvic pain due to pudendal

neuropathy. Obstet Gynecol 2000;95:306–309 [Medline]

source:

http://www.urmc.rochester.edu/smd/rad/pudendal.pdf

NOTE* At the site are also some pictures w. the surgery showing the buttocks

immediately after the surgery and other photos of the nerves, etc. that I couldn't copy here.

Dee T. (Copied from a PDF File, that took me forever, *grin*)

[Guest guest]

I agree, no mention of PT. Shame, shame.

Re: Pudendal Nerve Entrapment....

Good evening all, please excuse me while I vent!!!ARRRRRRGGG!!In section 6 where they say "what are the treatment options?"

Stop the offending activity .....ah 'cuse me but DUH!!! ( Doctor it hurts when I do this... Well, don't do that!)

Nerve blocks ...DRUGS

Neurontin and Elavil...DRUGS

Surgery!!! ( on what?? cut out the nerve?)Never a mention of fixing the cause and using the nonmanipulative techniques to relieve the pressure on the pudendal nerve right where it is entraped.UNBELIEVABLE! !!!! K. Ockler P.T.Dee Troll wrote:

Here's another I found in my 'mess'. Dee

============ ========= ========= ========= =

Pudendal

Neuralgia

Pudendal neuralgia is pain in the area supplied by the

pudendal nerve. This includes the external genitals, the

urethra, the anus, and the perineum.

Fred M. , Jr., M.D., M.S.

Professor of Obstetrics & Gynecology

Department of Obstetrics & Gynecology

University of Rochester Medical Center

601 Elmwood Avenue

Rochester, NY 14642-8668

Telephone:

Per Lennart Westesson, MD, PhD, DDS

Professor of Radiology

Division of Diagnostic and

Interventional Neuroradiology

University of Rochester Medical Center

601 Elmwood Avenue

Rochester, NY 14642-8648

Telephone:

S T R O N G H E A L T H

STRONG MEMORIAL HOSPITAL

For questions regarding clinical appointments, clinical examinations, and clinic visits call Dr. Fred 's office at .

For questions regarding pudendal nerve blocks please call

Dr. P-L Westesson's office at .

Frequently asked questions

1. What is Pudendal Nerve Entrapment?

Pudendal Nerve Entrapment is a pain condition for no apparent

reason in the lower central pelvic areas. These are the anal region,

perineum, and scrotum and penis or vulva.

Pain is worse upon sitting and less when standing or sitting on a

donut cushion or toilet seat.

The pain could be stinging, burning, stabbing, aching,

Knife-like, irritation, cramping, spasm, tightness, crawling on the

skin, twisting, pins and needles, numbness, and hyper sensitivity.

The pain is piercing and very comparable to a toothache. It often

starts in one place and progresses. Frequently there is also urinary,

anal, or sexual dysfunction. The pain is often on both sides.

2. What causes pudendal nerve entrapment?

Pudendal nerve entrapment is caused by entrapment of the

pudendal nerve. The initial constriction is often caused by

pressure or trauma. As the nerve swells it encounters a natural

constraint. Stretching or rubbing of the pudendal nerve can also

cause pudendal nerve entrapment.

3. What causes entrapment?

Pudendal nerve entrapment is usually precipitated by prolonged

sitting or trauma to the sitting area, combined with a

genetic and developmental susceptibility.

Pudendal nerve entrapment is common in high mileage (drivers) and

it is sometimes called Cyclist’s Syndrome.

4. What is Pudendal nerve entrapment frequently misdiagnosed

as?

Prostatodynia, nonbacterial prostatitis, idiopathic vulvodynia

(Idiopathic means unknown cause, dt), idiopathic orchialgia, idiopathic

proctalgia, idiopathic penile pain syndrome etc.

5. What are the most common symptoms of PNE?

The main symptom is pain with sitting. You feel great in the

AM until you sit for coffee, or drive to work. You get better with

lying down. The pain is in the distribution of the pudendal nerve....

genitalia, perineal or rectal. It can be any combination of these

areas depending on the part of the nerve entrapped.

6. What are the treatment options?

1. Avoiding the offending factor that causes pain

2. Three sequential image guided nerve blocks first with local

anesthetics and later possible combined with corticosteroids

3. Conservative medical treatment such as neurotin, Elavil

4. Surgery with decompression of the nerves is rarely done

7. If a patient suspects that they have pudendal neuralgia what

should they do to get help?

First, you need to make sure that other possible conditions

are ruled out. It is important to have a complete workup. Next is

an image guided nerve block and if you get numb in the area of

your pain and pain is gone you have a good indication that you

might have pudendal neuralgia.

8. Is there a connection between pudendal neuralgia and spinal

disorders and scoliosis?

No.

9. Which CPT codes are applicable for the image guided nerve

block?

64430 Injection, anesthetic agent; pudendal nerve

76360 Computed tomography guidance for needle placement

(e.g., biopsy, aspiration, injection, localization device),

radiological supervision and interpretation

Symptoms of Pudendal Neuralgia

Pudendal neuralgia is frequently caused by a mechanical and/or

inflammatory damage to this nerve. Symptoms include vague pains,

stabbing pains, burning sensations, pin pricking, numbness, twisting,

cold sensations and pulling sensations.

The area involved could be the rectum, anus, urethra, and perineum. In women, the vagina and vulva, the vaginal entrance, the minor and major labia, the mons veneris, and the clitoris.

In men, the penis and scrotum may be similarly affected. Pains and paraesthesias symptoms may extend as far as the groin, inner leg, buttocks, and abdomen.

The pain and paraesthesia may be perceived in only one of these areas, in several, or in all of them. These symptoms may be unilateral or bilateral or more distinct on one side than the other, and they are usually exacerbated by sitting position.

Utilization of a “doughnut” pillow and/or sitting on a toilet seat often provides some degree of comfort, as this lessens the pressure on the pudendal nerve(s). The skin overlying some of this region may react with extreme sensitivity to the slightest touch (hyperesthesia and allodynia), such that the affected person may avoid wearing certain items of clothing to avoid such discomfort.

Difficulty with normal voiding, with hesitancy or extreme urgency may cause repeated trips to the bathroom.

Bowel function may be abnormal, as well as painful.

Constipation is reported more frequently among those individuals diagnosed with pudendal neuralgia. Sexual intercourse may be problematic as penetration, for the woman, may be extremely painful, and for the males erectile dysfunction and/or pain with orgasm may predominate.

DIFFERENTIAL DIAGNOSIS

There are many other causes for similar symptoms and other

underlying conditions such as tumors, diseases of the spine or skin,

gynecological, urological, and/or proctological conditions should be

excluded before concluding that the patient suffer from pudendal neuralgia.

Specifically chronic or non-bacterial prostatitis, prostatodynia,

vulvodynia, vestibulitis, chronic pelvic pain syndrome, proctalgia,

anorectal neuralgia, pelvic contracture syndrome/pelvic congestion

or levator ani syndrome can resemble pudendal neuralgia.

Pain in the genital region is often brushed aside as a “psychosomatic” which leaves the patient feeling more distressed, uncertain, and helpless.

The pudendal nerve comes from the sacral plexus (S2-S4) and

enters the gluteal region through the lower part of the greater sciatic

foramen. It courses through the pelvis around ischial spine and

between the sacrospinous and sacrotuberous ligaments. It splits up

into the rectal/anal, perineal and clitorial/penis branches.

The nerve turns forward and downwards through the lower

sciatic foramen underneath the surface of the levator muscle into

the Alcock's canal where the nerve is flattened out between this

double fascia (aponeurosis) . The two most important narrow passages are around the ischial spine between the sacrospinous and

the sacrotuberous ligament (80%), and in the Alcock’s canal (20%).

Cycling, riding and long drives can kick off the symptoms of pudendal

neuralgia.

DIAGNOSIS

Pudendal neuralgia is a diagnosis of exclusion meaning that other causes for the symptoms must be excluded before the diagnosis of pudendal neuralgia is made.

Image guided pudendal nerve block

Image guided pudendal nerve block is the most important diagnostic test following history and physical examination.

The nerve is blocked by local anesthetic to see if symptoms can be eliminated by numbing the nerve. The block is done where the nerve is passing between the two ligaments or in the Alcock’s canal. In the first case, the block would be administered through the buttock into the area adjacent to the ischial tuberosity. In the second

case, the block is given directly into the Alcock’s canal.

Pudendal Nerve Motor Latency Test

Pudendal Nerve Motor Latency Test is similar to EMG (electromyogram) and measures the speed of nerve conduction. Electrodes fixed in the muscles of the perineum, in the rectum, in the muscles underneath the vulva around the vaginal entrance and the pudendal nerve is stimulated electrically while measuring the speed of the stimulus transmission. This speed is often slower when the nerve is compressed. This test is done relatively infrequently and has been replaced by image guided pudendal nerve blocks.

Pudendal nerve block and steroid injection

Image guided anesthetic and steroid blocks of the pudendal nerve

are used for both diagnosis and treatment. If the pain is relieved immediately following the block it suggests that the pudendal nerve is

the source of the symptoms and is probably trapped.

Symptoms often return as the local anesthetics wears off.

The steroids may or may not relieve symptoms for a longer period of time. If they do, it usually begins to improve about two weeks after the block, with improvements continuing for up to four to five weeks. Two to three blocks may be sufficient, alone, to cure the problem.

The purpose of the steroid is to reduce inflammation and allow the nerve more room to glide freely. After the injection, there might be a temporary deterioration due to

the steroid for a period of two to ten days (worsening of symptoms).

The blocks are done at the at the ischial spine between the sacrospinous and sacrotuberous ligaments or in the area of Alcock’s canal.

Botox (botulinum toxin) injections have been proposed but there

is no documentation as to its effect.

One injection protocol is to administer three sets of injections 1 weeks apart; the first injection is local anesthetics and if this has a positive effect the next two injections is a mixture of methylprednisolone (1 mL of 40 mg/mL solution) and bupivacaine (3 mL of 0.25% solution). The injections are usually given at the level of the ischial spine but if not successful the injection can be given directly into the pudendal canal (Alcock’s canal).

Usually the injections are unilateral, but patients with bilateral symptoms, both sides may be injected.

Medical Management

Medical management may include an anti-depressant and/or an

anti-seizure medication.

Surgery

Surgery is rarely done for this condition. The results are not well

documented and the operations are only available in a handful places

in France and US. If there is temporary or partial improvement after

the injections and if the nerve is still suspected of being compressed

some Doctors believe that decompression of the nerve through surgery may be an alternative for selected patients.

The nerve is exposed and freed from any entrapment or constriction along its entire course. The surgery is done under general anesthesia and lasts approximately 20-30 minutes per side. After the surgery, it takes a few to several months before a successful outcome can be demonstrated, as the nerve requires a relatively long period of time to heal. Often post surgical injections are needed. Surgery has been reported to be 60% successful, but there are no scientific studies published.

REFERENCES:

.. FM, The role of laparoscopy in the evaluation of chronic

pelvic pain: pitfalls with a negative laparoscopy. J Am Assoc

Gynecol Laparosc 1996; 4:1,85-94.

• FM. Adhesiolysis for pain relief. Operative Techniques

in Gynecologic Surgery 2000;5:3-12.

• FM. Chronic Pelvic Pain in Women. Amer J Managed

Care 2001;7:1001- 13.

• FM. Gynecologic Pain. In: Handbook of Pain Management,

3rd Edition. CD Tollison, JR Satterthwaite, JW Tollison,

eds. Lippincott, , and Wilkins: Philadelphia , 2001, pp

459-93.

• FM. Laparoscopic evaluation and treatment of women

with chronic pelvic pain. J Am Assoc Gynecol Laparosc

1994;1:325-31.

• FM. The role of laparoscopy as a diagnostic tool in

chronic pelvic pain. Bailliere’s Best Practice & Research in

Clinical Obstetrics & Gynaecology 2000;14:467- 94.

• FM. The role of laparoscopy in chronic pelvic pain:

promise and pitfalls. Obstet Gynecol Survey 1993;48:357- 87.

• http:/pn.jcon. org

• http:/pudendal. de/

• http:/pudendal. de/Publikationen /CTARTICLE. pdf

• http:/pudendal. info/

• http:/pudendal. info//info/ documents/

• http:/pudendal. info/documents/ CT_GuidedNerveBl ock.pdf

• http:/pudendal. info/info/ documetns/ IschialSpineAndP NE.pdf

• http://www.pudendal .de/Publikatione n/Anal%20pain% 20caus

ed%20bei%20Nervus% 20Pudendus% 20(Shafik) .pdf

• Mc JS, Spigos DG. Computed tomography-guided

pudendal block for treatment of pelvic pain due to pudendal

neuropathy. Obstet Gynecol 2000;95:306–309 [Medline]

source:

http://www.urmc. rochester. edu/smd/rad/ pudendal. pdf

NOTE* At the site are also some pictures w. the surgery showing the buttocks

immediately after the surgery and other photos of the nerves, etc. that I couldn't copy here.

Dee T. (Copied from a PDF File, that took me forever, *grin*)

You rock. That's why Blockbuster's offering you one month of Blockbuster Total Access, No Cost.

[Guest guest]

HI TOM...... *grin* what a nice surprise to hear from you!!!

TOTALLY agree... and you have every right to vent. Have at it any time. *smile*

Dee

Re: Pudendal Nerve Entrapment....

Good evening all, please excuse me while I vent!!!ARRRRRRGGG!!In section 6 where they say "what are the treatment options?"

Stop the offending activity .....ah 'cuse me but DUH!!! ( Doctor it hurts when I do this... Well, don't do that!)

Nerve blocks ...DRUGS Neurontin and Elavil...DRUGS Surgery!!! ( on what?? cut out the nerve?) Never a mention of fixing the cause and using the nonmanipulative techniques to relieve the pressure on the pudendal nerve right where it is entraped.UNBELIEVABLE!!!!! K. Ockler P.T.

[Guest guest]

This is a good basic

article Dee, but very outdated. It talks about “Surgery is rarely done for this condition.

The results are not well documented

and the operations are only available in a handful places in France and US.” Results are very well

documented now and surgery has been performed in the US in the last 3-4 years,

and there are about six doctors now in the US that do it.

nne

From:

VulvarDisorders [mailto:VulvarDisorders ] On

Behalf Of Dee Troll

Sent: Tuesday, April 01, 2008 5:32 PM

To: VULVAR DISORDERS LIST

Subject: Pudendal Nerve Entrapment....

Here's another I found in my 'mess'.

Dee

========================================

Pudendal

Neuralgia

Pudendal neuralgia is

pain in the area supplied by the

pudendal nerve. This

includes the external genitals, the

urethra, the anus,

and the perineum.

Fred M. , Jr., M.D., M.S.

Professor of Obstetrics &

Gynecology

Department

of Obstetrics & Gynecology

University

of Rochester Medical Center

601 Elmwood Avenue

Rochester, NY 14642-8668

Telephone:

Per Lennart Westesson, MD, PhD, DDS

Professor of Radiology

Division

of Diagnostic and

Interventional

Neuroradiology

University

of Rochester Medical Center

601 Elmwood Avenue

Rochester, NY 14642-8648

Telephone:

S T R O N G H

E A L T H

STRONG MEMORIAL HOSPITAL

For questions regarding clinical

appointments, clinical examinations, and clinic visits call Dr. Fred 's

office at .

For questions regarding pudendal

nerve blocks please call

Dr. P-L Westesson's office at

.

Frequently asked

questions

1. What is Pudendal

Nerve Entrapment?

Pudendal Nerve

Entrapment is a pain condition for no apparent

reason in the lower

central pelvic areas. These are the anal region,

perineum, and scrotum

and penis or vulva.

Pain is worse upon

sitting and less when standing or sitting on a

donut cushion or

toilet seat.

The pain could be

stinging, burning, stabbing, aching,

Knife-like,

irritation, cramping, spasm, tightness, crawling on the

skin, twisting, pins

and needles, numbness, and hyper sensitivity.

The pain is piercing

and very comparable to a toothache. It often

starts in one place

and progresses. Frequently there is also urinary,

anal, or sexual

dysfunction. The pain is often on both sides.

2. What causes

pudendal nerve entrapment?

Pudendal nerve

entrapment is caused by entrapment of the

pudendal nerve. The

initial constriction is often caused by

pressure or trauma.

As the nerve swells it encounters a natural

constraint.

Stretching or rubbing of the pudendal nerve can also

cause pudendal nerve

entrapment.

3. What causes

entrapment?

Pudendal nerve

entrapment is usually precipitated by prolonged

sitting or trauma to

the sitting area, combined with a

genetic and

developmental susceptibility.

Pudendal nerve

entrapment is common in high mileage (drivers) and

it is sometimes

called Cyclist’s Syndrome.

4. What is Pudendal

nerve entrapment frequently misdiagnosed

as?

Prostatodynia,

nonbacterial prostatitis, idiopathic vulvodynia

(Idiopathic means

unknown cause, dt), idiopathic orchialgia, idiopathic

proctalgia,

idiopathic penile pain syndrome etc.

5. What are the most

common symptoms of PNE?

The main symptom is

pain with sitting. You feel great in the

AM until you sit for

coffee, or drive to work. You get better with

lying down. The pain

is in the distribution of the pudendal nerve....

genitalia, perineal

or rectal. It can be any combination of these

areas depending on

the part of the nerve entrapped.

6. What are the

treatment options?

1. Avoiding the

offending factor that causes pain

2. Three sequential

image guided nerve blocks first with local

anesthetics and later

possible combined with corticosteroids

3. Conservative

medical treatment such as neurotin, Elavil

4. Surgery with

decompression of the nerves is rarely done

7. If a patient

suspects that they have pudendal neuralgia what

should they do to get

help?

First, you need to

make sure that other possible conditions

are ruled out. It is

important to have a complete workup. Next is

an image guided nerve

block and if you get numb in the area of

your pain and pain is

gone you have a good indication that you

might have pudendal

neuralgia.

8. Is there a

connection between pudendal neuralgia and spinal

disorders and

scoliosis?

No.

9. Which CPT codes

are applicable for the image guided nerve

block?

64430 Injection,

anesthetic agent; pudendal nerve

76360 Computed

tomography guidance for needle placement

(e.g., biopsy,

aspiration, injection, localization device),

radiological

supervision and interpretation

Symptoms of Pudendal Neuralgia

Pudendal neuralgia is

frequently caused by a mechanical and/or

inflammatory damage

to this nerve. Symptoms include vague pains,

stabbing pains,

burning sensations, pin pricking, numbness, twisting,

cold sensations and

pulling sensations.

The area involved

could be the rectum, anus, urethra, and perineum. In women, the vagina and

vulva, the vaginal entrance, the minor and major labia, the mons veneris, and

the clitoris.

In men, the penis and

scrotum may be similarly affected. Pains and paraesthesias symptoms may extend

as far as the groin, inner leg, buttocks, and abdomen.

The pain and

paraesthesia may be perceived in only one of these areas, in several, or in all

of them. These symptoms may be unilateral or bilateral or more distinct on one

side than the other, and they are usually exacerbated by sitting position.

Utilization of a

“doughnut” pillow and/or sitting on a toilet seat often provides some degree of

comfort, as this lessens the pressure on the pudendal nerve(s). The skin

overlying some of this region may react with extreme sensitivity to the

slightest touch (hyperesthesia and allodynia), such that the affected person

may avoid wearing certain items of clothing to avoid such discomfort.

Difficulty with normal

voiding, with hesitancy or extreme urgency may cause repeated trips to the

bathroom.

Bowel function may be

abnormal, as well as painful.

Constipation is

reported more frequently among those individuals diagnosed with pudendal

neuralgia. Sexual intercourse may be problematic as penetration, for the woman,

may be extremely painful, and for the males erectile dysfunction and/or pain

with orgasm may predominate.

DIFFERENTIAL DIAGNOSIS

There are many other

causes for similar symptoms and other

underlying conditions

such as tumors, diseases of the spine or skin,

gynecological,

urological, and/or proctological conditions should be

excluded before

concluding that the patient suffer from pudendal neuralgia.

Specifically chronic

or non-bacterial prostatitis, prostatodynia,

vulvodynia,

vestibulitis, chronic pelvic pain syndrome, proctalgia,

anorectal neuralgia,

pelvic contracture syndrome/pelvic congestion

or levator ani

syndrome can resemble pudendal neuralgia.

Pain in the genital

region is often brushed aside as a “psychosomatic” which leaves the patient

feeling more distressed, uncertain, and helpless.

The pudendal nerve

comes from the sacral plexus (S2-S4) and

enters the gluteal

region through the lower part of the greater sciatic

foramen. It courses

through the pelvis around ischial spine and

between the

sacrospinous and sacrotuberous ligaments. It splits up

into the rectal/anal,

perineal and clitorial/penis branches.

The nerve turns

forward and downwards through the lower

sciatic foramen

underneath the surface of the levator muscle into

the Alcock's canal

where the nerve is flattened out between this

double fascia

(aponeurosis). The two most important narrow passages are around the ischial

spine between the sacrospinous and

the sacrotuberous

ligament (80%), and in the Alcock’s canal (20%).

Cycling, riding and

long drives can kick off the symptoms of pudendal

neuralgia.

DIAGNOSIS

Pudendal neuralgia is

a diagnosis of exclusion meaning that other causes for the symptoms must be

excluded before the diagnosis of pudendal neuralgia is made.

Image guided pudendal

nerve block

Image guided pudendal

nerve block is the most important diagnostic test following history and physical

examination.

The nerve is blocked

by local anesthetic to see if symptoms can be eliminated by numbing the nerve.

The block is done where the nerve is passing between the two ligaments or in

the Alcock’s canal. In the first case, the block would be administered through

the buttock into the area adjacent to the ischial tuberosity. In the second

case, the block is

given directly into the Alcock’s canal.

Pudendal

Nerve Motor Latency Test

Pudendal Nerve Motor

Latency Test is similar to EMG (electromyogram) and measures the speed of nerve

conduction. Electrodes fixed in the muscles of the perineum, in the rectum, in

the muscles underneath the vulva around the vaginal entrance and the pudendal

nerve is stimulated electrically while measuring the speed of the stimulus

transmission. This speed is often slower when the nerve is compressed. This

test is done relatively infrequently and has been replaced by image guided

pudendal nerve blocks.

Pudendal nerve block

and steroid injection

Image guided anesthetic

and steroid blocks of the pudendal nerve

are used for both

diagnosis and treatment. If the pain is relieved immediately following the

block it suggests that the pudendal nerve is

the source of the

symptoms and is probably trapped.

Symptoms often return

as the local anesthetics wears off.

The steroids may or

may not relieve symptoms for a longer period of time. If they do, it

usually begins to improve about two weeks after the block, with improvements

continuing for up to four to five weeks. Two to three blocks may be sufficient,

alone, to cure the problem.

The purpose of the

steroid is to reduce inflammation and allow the nerve more room to glide

freely. After the injection, there might be a temporary deterioration due to

the steroid for a

period of two to ten days (worsening of symptoms).

The blocks are done

at the at the ischial spine between the sacrospinous and sacrotuberous

ligaments or in the area of Alcock’s canal.

Botox (botulinum

toxin) injections have been proposed but there

is no documentation

as to its effect.

One injection

protocol is to administer three sets of injections 1 weeks apart; the first

injection is local anesthetics and if this has a positive effect the next two

injections is a mixture of methylprednisolone (1 mL of 40 mg/mL solution) and

bupivacaine (3 mL of 0.25% solution). The injections are usually given at

the level of the ischial spine but if not successful the injection can be given

directly into the pudendal canal (Alcock’s canal).

Usually the injections

are unilateral, but patients with bilateral symptoms, both sides may be

injected.

Medical Management

Medical management

may include an anti-depressant and/or an

anti-seizure

medication.

Surgery

Surgery is rarely

done for this condition. The results are not well

documented and the

operations are only available in a handful places

in France and US. If

there is temporary or partial improvement after

the injections and if

the nerve is still suspected of being compressed

some Doctors believe

that decompression of the nerve through surgery may be an alternative for

selected patients.

The nerve is exposed

and freed from any entrapment or constriction along its entire course. The

surgery is done under general anesthesia and lasts approximately 20-30 minutes

per side. After the surgery, it takes a few to several months before a

successful outcome can be demonstrated, as the nerve requires a relatively long

period of time to heal. Often post surgical injections are needed. Surgery has

been reported to be 60% successful, but there are no scientific studies

published.

REFERENCES:

.. FM, The role of laparoscopy

in the evaluation of chronic

pelvic pain: pitfalls with a

negative laparoscopy. J Am Assoc

Gynecol Laparosc 1996; 4:1,85-94.

• FM. Adhesiolysis for pain

relief. Operative Techniques

in Gynecologic Surgery 2000;5:3-12.

• FM. Chronic Pelvic Pain

in Women. Amer J Managed

Care 2001;7:1001-13.

• FM. Gynecologic Pain. In:

Handbook of Pain Management,

3rd Edition. CD Tollison, JR

Satterthwaite, JW Tollison,

eds. Lippincott, , and

Wilkins: Philadelphia, 2001, pp

459-93.

• FM. Laparoscopic

evaluation and treatment of women

with chronic pelvic pain. J Am

Assoc Gynecol Laparosc

1994;1:325-31.

• FM. The role of

laparoscopy as a diagnostic tool in

chronic pelvic pain. Bailliere’s

Best Practice & Research in

Clinical Obstetrics &

Gynaecology 2000;14:467-94.

• FM. The role of

laparoscopy in chronic pelvic pain:

promise and pitfalls. Obstet

Gynecol Survey 1993;48:357-87.

• http:/pn.jcon.org

• http:/pudendal.de/

• http:/pudendal.de/Publikationen/CTARTICLE.pdf

• http:/pudendal.info/

• http:/pudendal.info//info/documents/

• http:/pudendal.info/documents/CT_GuidedNerveBlock.pdf

• http:/pudendal.info/info/documetns/IschialSpineAndPNE.pdf

• http://www.pudendal.de/Publikationen/Anal%20pain%20caus

ed%20bei%20Nervus%20Pudendus%20(Shafik).pdf

• Mc JS, Spigos DG. Computed

tomography-guided

pudendal block for treatment of

pelvic pain due to pudendal

neuropathy. Obstet Gynecol

2000;95:306–309 [Medline]

source:

http://www.urmc.rochester.edu/smd/rad/pudendal.pdf

NOTE* At the site are also some

pictures w. the surgery showing the buttocks

immediately

after the surgery and other photos of the nerves, etc. that I couldn't copy

here.

Dee T.

(Copied from a PDF File, that took me forever, *grin*)

[Guest guest]

Good evening all, please excuse me while I vent!!!

ARRRRRRGGG!!

In section 6 where they say "what are the treatment options?"

Stop the offending activity .....ah 'cuse me but DUH!!! ( Doctor

it hurts when I do this... Well, don't do that!)

Nerve blocks ...DRUGS

Neurontin and Elavil...DRUGS

Surgery!!! ( on what?? cut out the nerve?)

Never a mention of fixing the cause  and using the nonmanipulative

techniques to relieve the pressure on the pudendal nerve right where it

is entraped.

UNBELIEVABLE!!!!!

K. Ockler P.T.

Dee Troll wrote:

Here's another I found in my 'mess'.

Dee

 

========================================

Pudendal

Neuralgia

Pudendal neuralgia is

pain in the area supplied by the

pudendal nerve. This

includes the external genitals, the

urethra, the anus, and

the perineum.

 

 

Fred M. , Jr., M.D., M.S.

Professor of Obstetrics &

Gynecology

Department of Obstetrics & Gynecology

University of Rochester Medical

Center

601 Elmwood Avenue

Rochester, NY 14642-8668

Telephone:

 

Per Lennart Westesson, MD, PhD, DDS

Professor of Radiology

Division of Diagnostic and

Interventional Neuroradiology

University of Rochester Medical

Center

601 Elmwood Avenue

Rochester, NY 14642-8648

Telephone:

 

S T R O N G  H E A L T H

STRONG MEMORIAL HOSPITAL

 

For questions regarding clinical

appointments, clinical examinations, and clinic visits call Dr. Fred

's office at .

 

For questions regarding pudendal

nerve blocks please call

Dr. P-L Westesson's office at

.

 

Frequently asked

questions

 

1. What is Pudendal Nerve

Entrapment?

 

Pudendal Nerve Entrapment

is a pain condition for no apparent

reason in the lower

central pelvic areas. These are the anal region,

perineum, and scrotum and

penis or vulva.

 

Pain is worse upon

sitting and less when standing or sitting on a

donut cushion or toilet

seat.

 

The pain could be

stinging, burning, stabbing, aching,

Knife-like, irritation,

cramping, spasm, tightness, crawling on the

skin, twisting, pins and

needles, numbness, and hyper sensitivity.

 

The pain is piercing and

very comparable to a toothache. It often

starts in one place and

progresses. Frequently there is also urinary,

anal, or sexual

dysfunction. The pain is often on both sides.

 

2. What causes pudendal

nerve entrapment?

 

Pudendal nerve entrapment

is caused by entrapment of the

pudendal nerve. The

initial constriction is often caused by

pressure or trauma. As

the nerve swells it encounters a natural

constraint. Stretching or

rubbing of the pudendal nerve can also

cause pudendal nerve

entrapment.

 

3. What causes entrapment?

 

Pudendal nerve entrapment

is usually precipitated by prolonged

sitting or trauma to the

sitting area, combined with a

genetic and developmental

susceptibility.

Pudendal nerve entrapment

is common in high mileage (drivers) and

it is sometimes called

Cyclist’s Syndrome.

 

4. What is Pudendal nerve

entrapment frequently misdiagnosed

as?

 

Prostatodynia,

nonbacterial prostatitis, idiopathic vulvodynia

(Idiopathic means unknown

cause, dt), idiopathic orchialgia, idiopathic

proctalgia,

idiopathic penile pain syndrome etc.

 

5. What are the most

common symptoms of PNE?

 

The main symptom is pain

with sitting. You feel great in the

AM until you sit for

coffee, or drive to work. You get better with

lying down. The pain is

in the distribution of the pudendal nerve....

genitalia, perineal or

rectal. It can be any combination of these

areas depending on the

part of the nerve entrapped.

 

6. What are the treatment

options?

 

1. Avoiding the offending

factor that causes pain

2. Three sequential image

guided nerve blocks first with local

anesthetics and later

possible combined with corticosteroids

3. Conservative medical

treatment such as neurotin, Elavil

4. Surgery with

decompression of the nerves is rarely done

 

 

7. If a patient suspects

that they have pudendal neuralgia what

should they do to get

help?

 

First, you need to make

sure that other possible conditions

are ruled out. It is

important to have a complete workup. Next is

an image guided nerve

block and if you get numb in the area of

your pain and pain is

gone you have a good indication that you

might have pudendal

neuralgia.

 

8. Is there a connection

between pudendal neuralgia and spinal

disorders and scoliosis?

 

No.

 

9. Which CPT codes

are applicable for the image guided nerve

block?

 

64430 Injection,

anesthetic agent; pudendal nerve

76360 Computed tomography

guidance for needle placement

(e.g., biopsy,

aspiration, injection, localization device),

radiological supervision

and interpretation

 

 

Symptoms of Pudendal Neuralgia

 

Pudendal neuralgia is

frequently caused by a mechanical and/or

inflammatory damage to

this nerve. Symptoms include vague pains,

stabbing pains, burning

sensations, pin pricking, numbness, twisting,

cold sensations and

pulling sensations.

 

The area involved could

be the rectum, anus, urethra, and perineum. In women, the vagina and

vulva, the vaginal entrance, the minor and major labia, the mons

veneris, and the clitoris.

 

In men, the penis and

scrotum may be similarly affected. Pains and paraesthesias symptoms may

extend as far as the groin, inner leg, buttocks, and abdomen.

 

The pain and paraesthesia

may be perceived in only one of these areas, in several, or in all of

them. These symptoms may be unilateral or bilateral or more distinct on

one side than the other, and they are usually exacerbated by sitting

position.

 

Utilization of a

“doughnut” pillow and/or sitting on a toilet seat often provides some

degree of comfort, as this lessens the pressure on the pudendal

nerve(s). The skin overlying some of this region may react with extreme

sensitivity to the slightest touch (hyperesthesia and allodynia), such

that the affected person may avoid wearing certain items of clothing to

avoid such discomfort.

 

Difficulty with normal

voiding, with hesitancy or extreme urgency may cause repeated trips to

the bathroom.

 

Bowel function may be

abnormal, as well as painful.

 

Constipation is reported

more frequently among those individuals diagnosed with pudendal

neuralgia. Sexual intercourse may be problematic as penetration, for

the woman, may be extremely painful, and for the males erectile

dysfunction and/or pain with orgasm may predominate.

 

DIFFERENTIAL DIAGNOSIS

 

There are many other

causes for similar symptoms and other

underlying conditions

such as tumors, diseases of the spine or skin,

gynecological,

urological, and/or proctological conditions should be

excluded before

concluding that the patient suffer from pudendal neuralgia.

 

Specifically chronic or

non-bacterial prostatitis, prostatodynia,

vulvodynia, vestibulitis,

chronic pelvic pain syndrome, proctalgia,

anorectal neuralgia,

pelvic contracture syndrome/pelvic congestion

or levator ani syndrome

can resemble pudendal neuralgia.

 

Pain in the genital

region is often brushed aside as a “psychosomatic” which leaves the

patient feeling more distressed, uncertain, and helpless.

 

The pudendal nerve comes

from the sacral plexus (S2-S4) and

enters the gluteal region

through the lower part of the greater sciatic

foramen. It courses

through the pelvis around ischial spine and

between the sacrospinous

and sacrotuberous ligaments. It splits up

into the rectal/anal,

perineal and clitorial/penis branches.

 

The nerve turns forward

and downwards through the lower

sciatic foramen

underneath the surface of the levator muscle into

the Alcock's canal where

the nerve is flattened out between this

double fascia

(aponeurosis). The two most important narrow passages are around

the ischial spine between the sacrospinous and

the sacrotuberous

ligament (80%), and in the Alcock’s canal (20%).

Cycling, riding and long

drives can kick off the symptoms of pudendal

neuralgia.

 

DIAGNOSIS

 

Pudendal neuralgia is a

diagnosis of exclusion meaning that other causes for the symptoms must

be excluded before the diagnosis of pudendal neuralgia is made.

 

Image guided pudendal

nerve block

Image guided pudendal

nerve block is the most important diagnostic test following history and

physical examination.

 

The nerve is blocked by

local anesthetic to see if symptoms can be eliminated by numbing the

nerve. The block is done where the nerve is passing between the two

ligaments or in the Alcock’s canal. In the first case, the block would

be administered through the buttock into the area adjacent to the

ischial tuberosity. In the second

case, the block is given

directly into the Alcock’s canal.

 

Pudendal

Nerve Motor Latency Test

Pudendal Nerve Motor

Latency Test is similar to EMG (electromyogram) and measures the speed

of nerve conduction. Electrodes fixed in the muscles of the perineum,

in the rectum, in the muscles underneath the vulva around the vaginal

entrance and the pudendal nerve is stimulated electrically while

measuring the speed of the stimulus transmission. This speed is often

slower when the nerve is compressed. This test is done relatively

infrequently and has been replaced by image guided pudendal nerve

blocks.

 

 

Pudendal nerve block and

steroid injection

 

Image guided anesthetic

and steroid blocks of the pudendal nerve

are used for both

diagnosis and treatment. If the pain is relieved immediately following

the block it suggests that the pudendal nerve is

the source of the

symptoms and is probably trapped.

 

Symptoms often return as

the local anesthetics wears off.

The steroids may or may

not relieve symptoms for a longer period of time.  If

they do, it usually begins to improve about two weeks after the block,

with improvements continuing for up to four to five weeks. Two to three

blocks may be sufficient, alone, to cure the problem.

 

The purpose of the

steroid is to reduce inflammation and allow the nerve more room to

glide freely. After the injection, there might be a temporary

deterioration due to

the steroid for a period

of two to ten days (worsening of symptoms).

The blocks are done at

the at the ischial spine between the sacrospinous and sacrotuberous

ligaments or in the area of Alcock’s canal.

 

Botox (botulinum toxin)

injections have been proposed but there

is no documentation as to

its effect.

 

One injection protocol is

to administer three sets of injections 1 weeks apart; the first

injection is local anesthetics and if this has a positive effect the

next two injections is a mixture of methylprednisolone (1 mL of 40

mg/mL solution) and bupivacaine (3 mL of 0.25% solution). The

injections are usually  given at the level of the ischial

spine but if not successful the injection can be given directly into

the pudendal canal (Alcock’s canal).

 

Usually the injections

are unilateral, but patients with bilateral symptoms, both sides may be

injected.

 

Medical Management

 

Medical management may

include an anti-depressant and/or an

anti-seizure medication.

 

Surgery

Surgery is rarely done

for this condition. The results are not well

documented and the

operations are only available in a handful places

in France and US. If

there is temporary or partial improvement after

the injections and if the

nerve is still suspected of being compressed

some Doctors believe that

decompression of the nerve through surgery may be an alternative for

selected patients.

 

The nerve is exposed and

freed from any entrapment or constriction along its entire course. The

surgery is done under general anesthesia and lasts approximately 20-30

minutes per side. After the surgery, it takes a few to several months

before a successful outcome can be demonstrated, as the nerve requires

a relatively long period of time to heal. Often post surgical

injections are needed. Surgery has been reported to be 60% successful,

but there are no scientific studies published.

 

REFERENCES:

 

.. FM, The role of

laparoscopy in the evaluation of chronic

pelvic pain: pitfalls with a

negative laparoscopy. J Am Assoc

Gynecol Laparosc 1996; 4:1,85-94.

• FM. Adhesiolysis for

pain relief. Operative Techniques

in Gynecologic Surgery

2000;5:3-12.

• FM. Chronic Pelvic Pain

in Women. Amer J Managed

Care 2001;7:1001-13.

• FM. Gynecologic Pain.

In: Handbook of Pain Management,

3rd Edition. CD Tollison, JR

Satterthwaite, JW Tollison,

eds. Lippincott, , and

Wilkins: Philadelphia, 2001, pp

459-93.

• FM. Laparoscopic

evaluation and treatment of women

with chronic pelvic pain. J Am

Assoc Gynecol Laparosc

1994;1:325-31.

• FM. The role of

laparoscopy as a diagnostic tool in

chronic pelvic pain. Bailliere’s

Best Practice & Research in

Clinical Obstetrics &

Gynaecology 2000;14:467-94.

• FM. The role of

laparoscopy in chronic pelvic pain:

promise and pitfalls. Obstet

Gynecol Survey 1993;48:357-87.

 

• http:/pn.jcon.org

• http:/pudendal.de/

• http:/pudendal.de/Publikationen/CTARTICLE.pdf

• http:/pudendal.info/

• http:/pudendal.info//info/documents/

• http:/pudendal.info/documents/CT_GuidedNerveBlock.pdf

• http:/pudendal.info/info/documetns/IschialSpineAndPNE.pdf

• http://www.pudendal.de/Publikationen/Anal%20pain%20caus

ed%20bei%20Nervus%20Pudendus%20(Shafik).pdf

• Mc JS, Spigos DG.

Computed tomography-guided

pudendal block for treatment of

pelvic pain due to pudendal

neuropathy. Obstet Gynecol

2000;95:306–309 [Medline]

 

 

source:  

http://www.urmc.rochester.edu/smd/rad/pudendal.pdf

 

NOTE* At the site are also some

pictures w. the surgery showing the buttocks

immediately after the surgery and other photos

of the nerves, etc. that I couldn't copy here.

 

Dee T. (Copied from a PDF File, that took me

forever, *grin*) 

[Guest guest]

Thanks nne,

I didn't even look at the date.. but still thought 'some' of the information was good.

I wonder if that type of a surgery (or even the knowledge of it) is really that much more available today? I know you've more than done your research (definitely) and have shared it and with some excellent physicians names but I just wonder generally how aware people or physicians are of it overall and thank goodness there are those six you mentioned. Heck most aren't even aware of PT as even a starting place. *sigh*

Dee ~