Tom/Pudendal Nerve Entrapment....

[Guest guest]

Tom – PT does not work in all cases. I am going to very nice and

composed and not “vent” back at you, but I had the pudendal nerve decompression

surgery seven months ago, and I am very glad I did – in my case it was the only

thing left to do. And they do not “cut out the nerve”, they manipulate it

internally until it is free. Maybe you should read up on the procedure even

though you don’t agree with it, at least you will be informed. And yes, I had

months of good pelvic PT before I made the decision to have the surgery.

nne

From:

VulvarDisorders [mailto:VulvarDisorders ] On

Behalf Of K. Ockler

Sent: Wednesday, April 02, 2008 12:35 AM

To: VulvarDisorders

Subject: 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_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]

Hi nne and all.

YOu may have missunderstood my comments and so to clear this up.

#1. I am absolutly thrilled that you are much better after your surgery.

#2, I know perfectly well that they do not "cut the nerve out", I was

making a sacrcastic remark about the author's vague "surgery" comment.

The article was so matter-of-fact and left out so many other options..

"drugs and surgery" just makes the hair on the back of my necks stand

up.

#3. I could not agree with you more that PT (a somewhat generic term)

as it is currently being employed on this group of disorders does not

always work.

That is why I specifically mentioned the use of non-manipulative

manual therapy techniques and did not say PT.

These techniques are rare and not .. I repeat... not part

of the standard study or practice of Physical Therapists.

Muscle Energy and Counterstrain, when used appropriately can free up

the structures that are entraping the pudendal nerve.

All without surgery and especially without the risks that go along with

surgery.. like infection and the proliferation of scar tissue which

will just entrap the nerve again.

The nerve does not become entrapped unless something happens to change

the structure of the pelvis and pelvic floor.

So to surgically alter the anatomy and change it for ever when you have

not adressed the reason for the entrapement to me is just plane wrong!

(To me anyway.)

I realize all to well that my philosophy is somewhat eclectic and not

traditional but I am so enthusiastic about reaching as many as i can to

tell them... there are other means.

Hopefully I didn't ruffle anyones feathers more than a little and of

course, after being on this site for almost 8 years.. i'm used to

getting the rasberries every now and then. It is worth it even if I

can keep some of you from the knife and help you toward a safe and

effective cure.

By the way, I'm not all talk / smoke and mirrors....My new course, M3:

No Man's Land ... The all external evaluation and treatment of

disorders of the pelvis and plevic floor, is scheduled for

September 27-28th of this year at my clinic in Willoughby (Cleveland

Ohio.) This course is for female and male

therapists. The more therapists of either gender who are willing to

learn how to do this.... the better.

If you have the names and addresses of clinics that you are familiar

with and would like to give me their addresses, I will get the full

brochures out to them pronto!

Night all...

Tom Ockler PT

www.tomocklerpt.com

With these

millburytimes wrote:

Tom

– PT does not work in all cases. I am going to very nice and

composed and not “vent” back at you, but I had the pudendal nerve

decompression

surgery seven months ago, and I am very glad I did – in my case it was

the only

thing left to do. And they do not “cut out the nerve”, they manipulate

it

internally until it is free. Maybe you should read up on the procedure

even

though you don’t agree with it, at least you will be informed. And yes,

I had

months of good pelvic PT before I made the decision to have the surgery.

nne

From:

VulvarDisorders [mailto:VulvarDisorders ]

On

Behalf Of K. Ockler

Sent: Wednesday, April 02, 2008 12:35 AM

To: VulvarDisorders

Subject: 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

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