Pilot study: pudendal neuromodulation combined with pudendal nerve release in case of chronic perineal pain syndrome. The ENTRAMI technique: early results

Abstract Background Interstitial cystitis (IC) or bladder pain syndrome (BPS) is highly painful and disabling and probably the most misdiagnosed urologic condition. Its classic symptoms of perineal pain, urinary urgency, and frequency despite sterile urine cultures were already described more than a century ago in a report on soldiers during World War (WW) I due to chronic pudendal nerve compression. Objectives This article translates a report from 1915 on pudendal neuropathy and discusses its author Georg Zülzer (1870–1949). Methods An English translation of the German original is provided with the biography and work of Zülzer, his clinical observations are discussed regarding modern diagnosis and therapy of pudendal nerve compression. Results In his article entitled “Irritation of the Pudendal Nerve (Neuralgia). A Frequent Clinical Picture during War Feigning Bladder Catarrh,” Zülzer describes his observation of soldiers during WW I, presenting with a triad of perineal pain, urinary urgency, and frequency despite sterile urine cultures excluding urinary infections. He also documented a characteristic skin hypersensibility of the perineum in a rhomboid shape which corresponds to the innervation area of the pudendal nerve with its two branches deriving from the “pudendal plexus.” He regards this symptomology as rare during peace, but as disease of trench warfare which can be easily diagnosed regarding clear urine and a painful skin island overlying the area of the pudendal nerve as tested by simple needle examination. Zülzer, born in Germany, was forced to emigrate to the United States in 1934, was also an important pioneer of diabetes research using pancreas extracts from dogs as early as 1907. Conclusion In this historical description, dating from about a century ago, Georg Zülzer probably gave the first exact clinical description of symptoms due to pudendal nerve compression. Pudendal nerve compression should always be taken into account when examining and treating patients with symptoms of IC/BPS.

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

American Journal of Roentgenology ◽

10.2214/ajr.181.2.1810561 ◽

2003 ◽

Vol 181 (2) ◽

pp. 561-567 ◽

Cited By ~ 80

Author(s):

David M. Hough ◽

Keith H. Wittenberg ◽

Wojciech Pawlina ◽

Timothy P. Maus ◽

Bernard F. King ◽

...

Keyword(s):

Pudendal Nerve ◽

Nerve Entrapment ◽

Perineal Pain ◽

Injection Technique ◽

Ct Guided ◽

Perineural Injection ◽

Pudendal Nerve Entrapment ◽

Chronic Perineal Pain

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Surgical and anatomical landmarks for the perineal branch of the posterior femoral cutaneous nerve: implications in perineal pain syndromes

Journal of Neurosurgery ◽

10.3171/2008.11.jns081248 ◽

2009 ◽

Vol 111 (2) ◽

pp. 332-335 ◽

Cited By ~ 30

Author(s):

R. Shane Tubbs ◽

Joseph Miller ◽

Marios Loukas ◽

Mohammadali M. Shoja ◽

Ghaffar Shokouhi ◽

...

Keyword(s):

Pudendal Nerve ◽

Pain Syndrome ◽

Anatomical Study ◽

Cutaneous Nerve ◽

Perineal Pain ◽

Anatomical Landmarks ◽

Pain Syndromes ◽

Sacrotuberous Ligament ◽

Femoral Cutaneous Nerve ◽

Posterior Femoral Cutaneous Nerve

Object The perineal branch of the posterior femoral cutaneous nerve (PBPFCN) has received little attention in the literature. Because perineal pain syndromes can be disabling and pudendal nerve surgical decompression/block is often not efficacious, an anatomical study of this cutaneous nerve of the perineum seemed warranted. Methods The authors dissected 20 adult cadavers (40 sides) to identify the branching pattern and landmarks for the PBPFCN. Results This branch arose directly from the posterior femoral cutaneous nerve in 55% of sides and from the inferior cluneal nerve in 30% of sides. It was absent in 15% of sides. On average, the nerve coursed 4 cm inferior to the termination of the sacrotuberous ligament onto the ischial tuberosity. No PBPFCN was found to pierce the sacrotuberous ligament. The PBPFCN provided 2–3 branches to the medial thigh that continued on to the scrotum and labia major. In general, 2 small ascending branches were identified. In males, one ascending branch traveled inferior to the corpora cavernosum and anterior to the spermatic cord to cross the midline. The other ascending branch traveled to skin at the junction of the perineum and adductor tendon. A single descending branch, approximately 2 mm in diameter, traveled to the inferior scrotum anterior to the testicle in the male specimens and the lower labia majora in the female specimens. Communications between the PBPFCN and the perineal branch of the pudendal nerve were common. Conclusions Entrapment of the PBPFCN may be the cause of some forms of the perineal pain syndrome. Specific knowledge of the PBPFCN may assist surgeons in releasing and anesthetizing this cutaneous nerve of the perineum.

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