Pudendal neuralgia is a painful condition caused by inflammation, compression, or entrapment of the pudendal nerve.
Pudendal neuralgia is defined as a burning neuropathic pain in the distribution of the pudendal nerve, usually localized to the vulva, vagina, clitoris, perineum, and rectum in females, and to the glans penis, scrotum excluding testicles, perineum, and rectum in males.
Patients with chronic symptoms of intractable Pudendal neuralgia often present to our practice for consultation, to provide accurate diagnosis, and to discuss appropriate treatment options.
Expert Pain is the practice of Dr. Ioannis Skaribas, an interventional Pain Management Anesthesiologist , where patients with intractable Pudendal neuralgia, unable to find treatment for their painful symptomatology are seen for consult. Most of these patients present with very significant symptoms, chronic suffering, and having already been to multiple specialists without any success.
Because Pudendal Neuralgia is one of the most difficult chronic pain syndromes to diagnose and treat, suffering patients usually find themselves going from one specialist to another, whether it is neurologists, urogynecologists, surgeons, specialized physical therapists, and of course chronic pain Management specialist.
The Pudendal Nerve carries motor and sensory axons arising from the ventral rami of the sacral spinal nerves S2-S4. The nerve is found bilaterally. The left and right pudendal nerves give off branches, innervating regions of the rectal canal, anus, perineum, and external genitalia. The nerve is carrying sensations from the clitoris and penis, labia minora, vaginal vestibule, the vaginal canal, and the posterior aspects of the labia majora and scrotum and innervates the external anal and external urethral sphincters. The Pudendal nerve can be susceptible to injury, most notably during childbirth.
The painful symptomatology consists of burning, electric like, incapacitating pain involving the genital area often including the vagina clitoris, labia, penis in male patients, urethra, annus, the saddle area, the genital perineal area and pelvic floor, with the symptoms progressing or getting worse with seating, making it very difficult for patients to sit for prolonged periods of time. Severe pain can be experienced with urination, intercourse, defecation, or sometimes with any strain or simple movements.
Patients presenting with pudendal nerve involvement can be identified based on their history and presenting symptoms. Typically, neuropathy is noted in the distribution of the pudendal nerve. Common etiology are injuries that can be due to pelvic trauma, childbirth complications, chronic irritation, or even iatrogenic injuries from radiotherapy or surgical procedures in the pelvic region. Injuries to the pudendal nerve can occur during childbirth. The pudendal nerve is vulnerable to stretch injuries during labor. Mothers delivering children with above average birth weight are particularly susceptible injury. Patients who have chronic irritation of the pudendal nerve, may develop pudendal nerve entrapment or pudendal neuralgia. Any form of chronic pressure near the ischial spine can induce this injury. This syndrome has been noted to occur in professional cyclists, due to chronic irritation from the bicycle seat pressing the pudendal nerve against the ischial spine and/or the sacrospinous ligament. Other etiologies can be seen however including space occupying lesions such as tumors or vascular malformations, as well as infections of the area. Pudendal neuralgia usually causes bilateral perineal pain that is worse when sitting. The pain may progress and can result in severe discomfort, resistant to treatment, that can be debilitating. The accurate diagnosis of pudendal neuralgia is frequently delayed, and patients often go months or years of ineffective treatments after seeing a multitude of specialists. Perineal pain on sitting should be considered a typical sign of this condition.
Besides the symptomatology, history of present illness, and physical examination, specific diagnostic tests can be implemented to diagnose accurately Pudendal Neuralgia. Specialized imaging with MRI of the sacrospinous and sacrotuberous ligamental area to identify possible enlargement of the pudendal nerves and to rule out entrapment is a very common diagnostic procedure available. Electromyography and nerve conduction studies has been offered as another diagnostic step by specialized neurologists, however the diagnostic value of this specific test has been debated, and often patients cannot tolerate it because of the pain associated with the needle placement in the area. Ultrasound studies are also performed, and they do have a diagnostic value in terms of identifying muscular or ligamental hypertrophy and nerve entrapment. Both the MRI and the ultrasound when performed by experience diagnosticians can provide evidence of chronic inflammation in the area and facilitate accurate diagnosis. The standard of care diagnostic procedure to date, is a successful diagnostic pudendal nerve block performed either with CT or ultrasound guidance.
Although Pudendal Neuralgia is common, it is often over-diagnosed.
Not all pelvic Pain is Pudendal Neuralgia.
Common conditions that could mimic pudendal neuralgia include interstitial cystitis, chronic or non-bacterial prostatitis, Pelvic inflammatory disease, vulvodynia, vulvar vestibulitis, chronic pelvic pain syndrome (CPPS), endometriosis, coccygodynia, Lumbosacral radiculitis, CRPS1 and CRPS 2 of the pelvic floor and perineal area, atypical chronic proctalgia fugax, and idiopathic perineal neuropathy.
The conservative treatment options for pudendal neuralgia can include: physical therapy, pelvic floor muscle manipulation and massage, topical applications, as well as different types and categories of medications, including gabapentin, pregabalin, duloxetine, amitriptyline, and nortriptyline, Effexor, and muscle relaxants such as tizanidine, and Baclofen. Most of these treatment options are usually unsuccessful and associated with significant side effects. Unfortunately most of the suffering patients with pudendal neuralgia are dependent on opioid medications. The severity of the symptoms as well as the lack of meaningful treatment options offered, commit these patients to high doses of narcotics with all the detrimental end-organ side effects, and with the very real danger of accidental overdose and death.
Interventional Pain Management offers several therapeutic options and should be offered early to the patient suffering from Pudendal neuralgia.
These include:
Pudendal nerve blocks. This procedure usually reserved for diagnostic purposes, and perform with CT and more often ultrasound guidance, can reduce inflammation, decompress nerve entrapment, desensitize the nerves, reduce rapid firing, and provide pain relief. For the most part the pain relief is usually temporary and requires multiple repeat procedures over time.
Pudendal nerve radio frequency ablation rhizotomy. This is usually not a favorable option, although some physicians are utilizing, and it and carries the high risk of chronic neuritis with worsening symptomatology.
Ganglion Impar Block. The ganglion impar, is a singular sympathetic ganglion in the anterior endplate of the sacrococcygeal junction, that modulates sympathetic outflow from the perineal and pelvic area and is often used to provide pain relief for painful neuropathies of the perineum said such as pudendal neuralgia. This procedure also needs repeated injections and can provide pain relief for certain periods of time.
Dorsal Root Ganglion (DRG) stimulation. Since its introduction to the US in 2016, Dorsal Root Ganglion stimulation is a form of neuromodulation the targets the dorsal root ganglia of specific spinal nerves providing for targeted therapy in selective areas of the body such as the perineum and pelvis. Neurostimulation of the S2 and S3 dorsal ganglia bilaterally has provided satisfactory long-term results and has been in practice since the therapy's introduction. Alternative protocols implement L1 and S3 dorsal ganglia neuro stimulation, with the choice of the target areas being dependent on the presenting symptomatology. The period of trial, ranging from three to seven days, where temporary therapy is implemented, can provide clear attestation to the treatment’s therapeutic outcome, and validate implantation of these microscopic neurostimulation electrodes, operated by a very small unit resembling a small pacemaker. This treatment is to date the most successful long-term therapy for intractable painfull Pudendal neuralgia.
Spinal Cord Stimulation. For certain categories of patients, and for the ones that dorsal ganglion stimulation is not successful, spinal cord stimulation is an alternative long term treatment option. Different modes of spinal cord stimulation including tonic, burst, or high frequency have been used with success providing long term pain relief.
Surgery. Surgical decompression of the Alcock’s (Pudendal) canal has been utilized by certain neurosurgeons for many years with variable and usually unfavorable outcomes.
Expert Pain is the practice of Dr. Ioannis Skaribas MD, FASA, DABA
Fellow of the American Society of Anesthesiologists.
Diplamate of the American Board of Anesthesiology
Dr. Skaribas is an Interventional Anesthesiologist, double board certified in Anesthesiology and Pain Medicine, and fellowship trained in Interventional Pain Management at Baylor College of Medicine in Houston TX.
Dr. Skaribas has more than 20 years’ experience in the treatment of advanced intractable painful syndromes including Pudendal Neuralgia, and he is an expert in DRG, Spinal Cord Stimulation, and Interventional Pain Medicine. He is a key opinion leader in Spinal Cord Stimulation and Neuromodulation both nationally and internationally with multiple publications in the field.
For more information, visit expertpaincare.com or call us at 832-862-7246.
https://www.expertpaincare.com/
Bibliography
Calvillo, Octavio, Ioannis M. Skaribas, and Carl Rockett. "Computed tomography-guided pudendal nerve block. A new diagnostic approach to long-term anoperineal pain: a report of two cases." Regional Anesthesia and Pain Medicine 25.4 (2000): 420-423.
Levesque, A., Bautrant, E., Quistrebert, V., Valancogne, G., Riant, T., Beer Gabel, M., Leroi,M., Jottard, K., Bruyninx, L., Amarenco, G., Quintas, L., Picard, P., Vancaillie, T., Leveque, C., Mohy, F., Rioult, B., Ploteau, S., Labat, J.-J., Guinet-Lacoste, A., Robert, R. (2022). Recommendations on the management of pudendal nerve entrapment syndrome: A formalised expert consensus. European Journal of Pain, 26, 7–17.
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Deer, Timothy R.,Jason Pope, Ioannis Skaribas et al. "The neuromodulation appropriateness consensus committee on best practices for dorsal root ganglion stimulation." Neuromodulation: Technology at the Neural Interface 22.1 (2019): 1-35. |
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Deer, Timothy, Ioannis Skaribas, Christopher Nelson, Jerry Tracy, Stuart Meloy, Amit Darnule, John Salmon et al. "Interim results from the partnership for advancement in neuromodulation pain registry." Neuromodulation: Technology at the Neural Interface 17, no. 7 (2014): 656-664.
Deer, Timothy R., Ioannis M. Skaribas, Nameer Haider, John Salmon, Chong Kim, Christopher Nelson, Jerry Tracy et al. "Effectiveness of cervical spinal cord stimulation for the management of chronic pain." Neuromodulation: Technology at the Neural Interface 17, no. 3 (2014): 265-271.
Deer, Timothy, Ioannis Skaribas, Tory McJunkin, Christopher Nelson, John Salmon, Amit Darnule, John Braswell, Marc Russo, and Omar Fernando Gomezese. "Results from the partnership for advancement in neuromodulation registry: a 24-month follow-up." Neuromodulation: Technology at the Neural Interface 19, no. 2 (2016): 179-187.
