Chronic Perineal Pain Caused by Pudendal Nerve Entrapment: Anatomy and CT-Guided Perineural Injection Technique (original) (raw)

Anatomical basis of chronic pelvic pain syndrome: the ischial spine and pudendal nerve entrapment

Medical Hypotheses, 2002

Antolak SJ Jr, Hough DM, Pawlina W, Spinner RJ: Anatomical basis of chronic pelvic pain syndrome: the ischial spine and pudendal nerve entrapment. Chronic pelvic pain syndrome is a conundrum that may be explained partly by pudendal nerve entrapment (PNE), which causes neuropathic pain. In men with PNE, aberrant development and subsequent malpositioning of the ischial spine appear to be associated with athletic activities during their youth. The changes occur during the period of development and ossification of the spinous process of the ischium.

Pelvic Pain of Pudendal Nerve Origin: Surgical Outcomes and Learning Curve Lessons

Journal of Reconstructive Microsurgery, 2015

Reconstructive microsurgery may directly involve the pudendal nerve during vaginal reconstruction, 1-4 groin hydradenitis suppurativa reconstruction, 5,6 rectal reconstruction, 7-9 transgender reconstruction, 10-12 inferior gluteal artery perforator flaps for breast reconstruction, 13-16 labial reconstruction, 17-19 salvage procedures after gynecologic mesh interventions for urinary incontinence, 20-22 and following urologic procedures such as prostatectomy. Injury to the branches of the pudendal nerve results in pain syndromes that have proven difficult to treat, with success rates for the most commonly done surgical approach having an expectation that 70% of patients will improve by > 2 on a 10-point Likert scale, and just 20% achieving an excellent result (►Table 1). Recognizing that peripheral nerve surgery is the basis for treatment of refractory pelvic pain related to the pudendal nerve, it is incumbent for the reconstructive microsurgeon to approach the problem from the standpoint of (1) determining that the pudendal nerve is the nerve primarily transmitting Keywords ► pudendal nerve ► neurolysis ► neuroma

Asymmetrical pudendal nerve damage in pelvic floor disorders

International Journal of Colorectal Disease, 1988

Differences in the left and right pudendal nerve terminal motor latencies have been observed in patients with pelvic floor disorders. Until now the mean value of the left and right pudendal latencies has been used as the index of pudendal neuropathy. In 22 patients of a group of 156 patients studied the pudendal nerve terminal motor latency was abnormally raised on one side only. These patients are thought to have pudendal neuropathy whether or not the mean value of the left and right pudendal latencies is also raised. This observation may have therapeutic implications.

Laparoscopic transperitoneal pudendal nerve and artery release for pudendal entrapment syndrome

Surgical Endoscopy, 2020

Introduction Pudendal nerve and artery entrapment is an underdiagnosed pathology responsible of several urinary, sexual and anorectal complaints. The aim of our study was to evaluate safety and feasibility of laparoscopic transperitoneal pudendal nerve and artery release in a large retrospective cohort of patients with pudendal nerve entrapment syndrome with both a short and long-term follow-up. Technical details and outcomes are also reported. Methods A series of 235 patients with pudendal syndrome underwent laparoscopic transperitoneal pudendal canal release between June 2015 and February 2020. Operative data were recorded prospectively for all patients. A complete history, pain visual analog scale (VAS) for perineodynia, and three scores evaluating the main symptoms (USP, IIEF-5, PAC-SYM) were obtained before and at least 24 months after surgery for 32 patients only. Post-operative complications were also evaluated using Clavien-Dindo classification at regular interval. Results The mean operating time per side was 33.9 ± 6.8 min and the average hospital stay was 1.9 ± 0.3 days. Blood loss was 20 cc ± 10 cc with no patients needing transfusion. The only significant per-operative complication was hemorrhage (600 ml) in one patient induced by a pudendal artery laceration, successfully treated by laparoscopic suturing. Post-operative complications were noted in 18.7% of patients with no serious Clavien-Dindo complications. Perineodynia VAS dropped from 6.8 ± 0.9 to 2.2 ± 1.8 after surgery (p < 0.001). Mean IIEF-5 scores significantly improved one month after the surgery (15.2 vs 19.3, p = 0.036). Mean USP scores significantly improved for the dysuria domain (4.2 vs 1.6, p = 0.021) but not for stress urinary incontinence (3.9 vs 4.1, p = 0.082) or overactive bladder symptoms (14.1 vs 13.8, p = 0.079). Mean PAC-SYM scores significantly improved after the procedure (1.8 vs 1.1, p < 0.001). Conclusion A complete laparoscopic pudendal nerve and artery release, from the sciatic spine through the Alcock's canal, is a fast and safe surgery with promising functional results. A large prospective trial is needed to validate such an approach.

Magnetic resonance imaging of pudendal nerve: technique and results

Pelviperineology, 2021

INTRODUCTION Since its first description in 1992 and subsequent years, magnetic resonance imaging (MRI) of pudendal nerve has rapidly gained wide acceptance by the medical community as a valuable tool for decision-making and therapy planning in patients with chronic pelvic pain syndromes. The term “MRneurography” has come into practical use to describe the direct depiction of nerves in the body using special modifications of the standard MR imaging technique which allow detection of the signal arising from inside the nerve itself rather than from the surrounding tissues. More specifically, given the intraneural source of the signal, the images obtained during the examination were thought to provide important information about the internal state of the nerve such as the presence of irritation, nerve swelling, compression, pinch or injury. From the technical point of view, the basic principle for a successful examination includes suppression of the signal coming from the bright fat, s...

Ultrasound-guided injections in pelvic entrapment neuropathies

Journal of Ultrasonography, 2021

Pelvic entrapment neuropathies represent a group of chronic pain syndromes that significantly impede the quality of life. Peripheral nerve entrapment occurs at specific anatomic locations. There are several causes of pelvic entrapment neuropathies, such as intrinsic nerve abnormality or inflammation with scarring of surrounding tissues, and surgical interventions in the abdomen, pelvis and the lower limbs. Entrapment neuropathies in the pelvic region are not widely recognized, and still tend to be underdiagnosed due to numerous differential diagnoses with overlapping symptoms. However, it is important that entrapment neuropathies are correctly diagnosed, as they can be successfully treated. The lateral femoral cutaneous nerve, ischiadic nerve, genitofemoral nerve, pudendal nerve, ilioinguinal nerve and obturator nerve are the nerves most frequently causing entrapment neuropathies in the pelvic region. Understanding the anatomy as well as nerve motor and sensory functions is essentia...

CT-guided Perineural Injections for Chronic Pelvic Pain

Radiographics : a review publication of the Radiological Society of North America, Inc

Chronic pelvic pain is a disabling condition that affects a large number of men and women. It may occur after a known inciting event, or it could be idiopathic. A common cause of pelvic pain syndrome is neuropathy of the pelvic nerves, including the femoral and genitofemoral nerves, ilioinguinal and iliohypogastric nerves, pudendal nerve, obturator nerve, lateral and posterior femoral cutaneous nerves, inferior cluneal nerves, inferior rectal nerve, sciatic nerve, superior gluteal nerve, and the spinal nerve roots. Pelvic neuropathy may result from entrapment, trauma, inflammation, or compression or may be iatrogenic, secondary to surgical procedures. Imaging-guided nerve blocks can be used for diagnostic and therapeutic management of pelvic neuropathies. Ultrasonography (US)-guided injections are useful for superficial locations; however, there can be limitations with US, such as its operator dependence, the required skill, and the difficulty in depicting various superficial and de...