scholarly journals Pulsed Radiofrequency Ablation of Pudendal Nerve for Treatment of a Case of Refractory Pelvic Pain

2017 ◽  
Vol 3 (20;3) ◽  
pp. E451-E454 ◽  
Author(s):  
Stephanie Jones
Keyword(s):  
Radiofrequency Ablation ◽  
Pain Relief ◽  
Pelvic Pain ◽  
Pudendal Nerve ◽  
Pudendal Neuropathy ◽  
Ischial Spine ◽  
Pulsed Radiofrequency ◽  
Pudendal Neuralgia ◽  
Mr Neurography ◽  
The Right

Pudendal neuralgia (PN) is a result of pudendal nerve entrapment or injury, also called “Alcock syndrome.” Pain that develops is often chronic, and at times debilitating. If conservative measures fail, invasive treatment modalities can be considered. The goal of this case report is to add to a small body of literature that a pulsed radiofrequency (PRF) ablation can be effectively used to treat PN and to show that high resolution MR neurography imaging can be used to detect pudendal neuropathy. Case Presentation: We present a case of a 51-year-old woman with 5 years of worsening right groin and vulva pain. Various medication trials only lead to limited improvement in pain. The first diagnostic right pudendal nerve block was done using 3 mL of 0.25% bupivacaine with 6mg of betamethasone using a transgluteal technique and a target of the right ischial spine; this procedure resulted in ~8 hours of > 50% pain relief. The patient was then referred for MR neurography of the lumbosacral plexus. This study revealed increased signal of the right pudendal nerve at the ischial spine and in the pudendal canal, findings consistent with the clinical picture of PN. Six weeks after the initial block, the patient underwent a second right transgluteal pudendal nerve block, utilizing 3 mL of 0.25% bupivacaine with 40 mg of triamcinolone acetonide; this procedure resulted in ~8 hours of 100% pain relief. Satisfied with these results the patient decided to undergo pudendal nerve PRF ablation for possible long-term relief. For this therapeutic procedure, a right transgluteal approach was again utilized. PRF ablation was performed for 240 seconds at 42° Celsius. Following this ablation the patient reported at least 6 weeks of significant (> 50%) pain relief. Discussion and Conclusion: In this paper we presented a case of successful treatment of PN with PRF ablation and detection of pudendal neuropathy on MR neurography. We believe that transgluteal PRF ablation for PN might be an effective, minimally invasive option for those patients that have failed conservative management. MR neurography employed in this case is not only helpful in confirming the diagnosis of PN but could also be useful in ruling out other causes of pelvic pain, such as genitofemoral neuropathy, endometriosis, adenomyosis, or pelvic mass lesion. To conclude, transgluteal PRF ablation can serve as a viable treatment option for mitigating symptoms of pudendal neuropathy and MR neurography is useful in confirming a clinically suspected diagnosis of PN. Key words: Pelvic pain, pudendal neuralgia, MR neurography, pulsed radiofrequency ablation, transgluteal technique, Alcock canal syndrome

scholarly journals Measuring the Quality of Pudendal Nerve Perineural Injections

2016 ◽  
Vol 4;19 (4;5) ◽  
pp. 299-306 ◽  
Author(s):  
Stanley Antolak, Jr
Keyword(s):  
Pain Relief ◽  
Pelvic Pain ◽  
Local Anesthetic ◽  
Private Practice ◽  
Pain Control ◽  
Pudendal Nerve ◽  
P Value ◽  
Pudendal Neuropathy ◽  
Nerve Branch

Background: Pudendal neuropathy is a tunnel syndrome characterized by pelvic pain and may include bowel, bladder, or sexual dysfunction or a combination of these. One treatment method, pudendal nerve perineural injections (PNPIs), uses infiltration of bupivacaine and corticosteroid around the nerve to provide symptom relief. Bupivacaine also anesthetizes the skin in the receptive field of the nerve that is injected. Bupivacaine offers rapid pain relief for several hours while corticosteroid provides delayed pain control often lasting 3 to 5 weeks. Not all pudendal nerve blocks may provide complete pain relief but long-term pain control from the steroid appears to be associated with immediate response to bupivacaine. We offer a method of evaluating the quality of a pudendal block on the day it is performed using pinprick sensation evaluation. Objective: To demonstrate that pinprick sensory changes provide a simple and rapid method of measuring response to local anesthetic and pain reduction provided by a PNPI on the day it is performed. This response defines the quality of each PNPI. Study Design: This is a case series based on retrospective review of a private practice database that is maintained by HealthEast hospitals in Minnesota. Database information includes standard physical examination, recording techniques, and treatment processes that had been in place for several years. Setting: Private practice in United States. Methods: Patients with a diagnosis of pudendal neuropathy are treated with PNPIs. Two hours after each block, 2 endpoints are measured: response to a sensory pinprick examination of the pudendal territory and difference in patient-reported pain level before and after nerve block. Fifty-three men from a private practice treating only pelvic pain received the treatment in 2005. Reported pain level was not recorded for 2 patients. Results: Bupivacaine in perineural injections produces varying degrees of analgesia or hypalgesia to pinprick. Normal pinprick response suggests pudendal nerves were not penetrated by bupivacaine. Patient responses varied from complete, i.e. all 6 branches anesthetized to none. Most men had 2 – 5 nerve branches anesthetized. One man had a single nerve branch that responded to bupivacaine. Three men failed to respond to local anesthetic. Changes in pre-PNPI to post-PNPI pain scores were significantly decreased (n = 51, P-value < 0.0001), indicating that bupivacaine in the PNPI reduced pain. Forty-one patients (80.4%) indicated less pain after the procedure and only 2 patients (4.0%) indicated more pain. The number of nerve branches successfully anesthetized was also significantly correlated with change in score. On average, an additional successful nerve branch anesthetized corresponded to a drop of about 0.66 in the change score (n = 51, P - value = 0.0005). Conclusion: PNPIs relieve pain. Anesthesia affected all 6 pudendal nerve branches in only 13.2% of patients. Complete pain relief occurred in 39.2%. This argues against use of perineural pudendal blockade as a diagnostic test. Pain relief after PNPI is associated with number of nerve branches that are anesthetized. At 2 hours after a PNPI its quality (the number of the 6 nerve branches with reduced response to pinprick from the perineural local anesthetic) is associated with subjective reduction of pain. Key words: Pudendal neuralgia, chronic perineal pain, pudendal nerve block, sensory examination, neurologic examination, pain management, chronic pelvic pain syndrome

Initial experience of CT-guided pulsed radiofrequency ablation of the pudendal nerve for chronic recalcitrant pelvic pain

2019 ◽  
Vol 74 (11) ◽  
pp. 897.e17-897.e23 ◽  
Author(s):  
M.D. Collard ◽  
Y. Xi ◽  
A.A. Patel ◽  
K.M. Scott ◽  
S. Jones ◽  
...  
Keyword(s):  
Radiofrequency Ablation ◽  
Pelvic Pain ◽  
Pudendal Nerve ◽  
Initial Experience ◽  
Pulsed Radiofrequency ◽  
Ct Guided

scholarly journals Role of 3 Tesla MR Neurography and CT-guided Injections for Pudendal Neuralgia: Analysis of Pain Response

2019 ◽  
Vol 4 (22;4) ◽  
pp. E333-E344
Author(s):  
Avneesh Chhabra
Keyword(s):  
Study Design ◽  
Pelvic Pain ◽  
Chronic Pelvic Pain ◽  
Pudendal Nerve ◽  
Pain Response ◽  
Pudendal Neuropathy ◽  
Pudendal Neuralgia ◽  
Ct Guided ◽  
Perineural Injection

Background: Magnetic resonance neurography (MRN) has an increasing role in the diagnosis and management of pudendal neuralgia, a neurogenic cause of chronic pelvic pain. Objective: The objective of this research was to determine the role of MRN in predicting improved pain outcomes following computed tomography (CT)-guided perineural injections in patients with pudendal neuralgia. Study Design: This study used a retrospective cross-sectional study design. Setting: The research was conducted at a large academic hospital. Methods: Patients: Ninety-one patients (139 injections) who received MRN and CT-guided pudendal blocks were analyzed. Intervention: A 3Tesla (T) scanner was used to evaluate the lumbosacral plexus for pudendal neuropathy. Prior to receiving a CT-guided pudendal perineural injection, patients were given pain logs and asked to record pain on a visual analog scale. Measurement: MRN findings for pudendal neuropathy were compared to the results of the CTguided pudendal nerve blocks. Injection pain responses were categorized into 3 groups – positive block, possible positive block, and negative block. Statistical Tests: A chi-square test was used to test any association, and a Cochran-Armitage trend test was used to test any trend. Significance level was set at .05. All analyses were done in SAS Version 9.4 (SAS Institute, Inc., Cary, NC). Results: Ninety-one patients (139 injections) who received MRN were analyzed. Of these 139 injections, 41 were considered positive (29.5%), 52 of 139 were possible positives (37.4%), and 46 of 139 were negative blocks (33.1%). Of the patients who had a positive pudendal block, no significant difference was found between the MRN result and the pudendal perineural injection response (P = .57). Women had better overall response to pudendal blocks, but this response was not associated with MRN findings (P = .34). However, positive MRN results were associated with better pain response in men (P = .005). Patients who reported bowel dysfunction also had a better response to pudendal perineural injection (P = .02). Limitations: Some limitations include subjectivity of pain reporting, reporting consistency, absence of a control group, and the retrospective nature of the chart review. Conclusion: Pudendal perineural injections improve pain in patients with pudendal neuralgia and positive MRN results are associated with better response in men. Key words: MRI, MRN, CT injection, pudendal neuralgia, pudendal nerve, pelvic pain, chronic pelvic pain, pudendal neuropathy

scholarly journals Successful Treatment of Refractory Pudendal Neuralgia with Pulsed Radiofrequency

2009 ◽  
Vol 3;12 (3;5) ◽  
pp. 633-638 ◽  
Author(s):  
Ellen E. Rhame
Keyword(s):  
Pain Relief ◽  
Pudendal Nerve ◽  
Medication Management ◽  
Decompression Surgery ◽  
Pulsed Radiofrequency ◽  
Pudendal Neuralgia ◽  
Nerve Blocks ◽  
Burning Pain ◽  
Radiofrequency Current ◽  
Current Therapies

Pudendal neuralgia (PN) involves severe, sharp pain along the course of the pudendal nerve, often aggravated with sitting. Current therapies include medication management, nerve blocks, decompression surgery, and neuromodulation. The ideal management for PN has not been determined. We present a case of a female with 1.5 years of sharp, burning pain of the left gluteal and perineal regions. She could not sit for longer than 10 to 15 minutes. Sacroiliac joint, epidural, and piriformis injections did not improve her pain. She had tried physical therapy, occupational therapy, massage, and acupuncture but the pain persisted. Medication treatment with oxycodone-acetaminophen, extended release morphine sulfate, amitriptyline, and gabapentin provided only minor relief and she had failed other multianalgesic therapy. She had been unable to work at her desk job for over a year. She had a positive response to 2 diagnostic pudendal nerve blocks with lidocaine that provided pain relief for several hours. This patient elected to undergo pulsed radiofrequency (PRF) of the left pudendal nerve in hopes of achieving a longer duration and improved pain relief. PRF was carried out at a frequency of 2 Hz and a pulse width of 20 milliseconds for a duration of 120 seconds at 42 degrees Celsius. After the procedure she reported tolerating sitting for 4 to 5 hours. Her multianalgesic therapy was successfully weaned. At 5 months follow-up she felt motivated to return to work. One and a half years after the procedure the patient is only taking oxycodone-acetaminophen for pain relief and still has good sitting tolerance. There were no procedure-related complications. To our knowledge PRF for the treatment of PN has not been reported elsewhere in the literature. PRF is a relatively new procedure and is felt to be safer than continuous radiofrequency. Current literature suggests that PRF delivers an electromagnetic field, which modifies neuro-cellular function with minimal cellular destruction. We conclude that PRF of the pudendal nerve offers promise as a potential treatment of PN that is refractory to conservative therapy. Key words: pudendal neuralgia, pulsed radiofrequency, pudendal nerve, neuromodulation

Poster 420 Pudendal Nerve Radiofrequency Ablation for Treatment of Atypical Pelvic Pain: A Case Report

PM&R ◽  
2012 ◽  
Vol 4 ◽  
pp. S334-S334
Author(s):  
Wes Wiltse ◽  
Ake Evans ◽  
Jeremiah Ladd ◽  
Francis P. Lagattuta ◽  
David C. Majors ◽  
...  
Keyword(s):  
Case Report ◽  
Radiofrequency Ablation ◽  
Pelvic Pain ◽  
Pudendal Nerve

scholarly journals Pudendal Neuralgia Due to Pudendal Nerve Entrapment: Warning Signs Observed in Two Cases and Review of the Literature

2016 ◽  
Vol 3;19 (3;3) ◽  
pp. E449-E454 ◽  
Author(s):  
Stéphane Ploteau
Keyword(s):  
Diagnostic Criteria ◽  
Pelvic Pain ◽  
Pudendal Nerve ◽  
Warning Signs ◽  
Nerve Entrapment ◽  
Perineal Pain ◽  
Pudendal Neuralgia ◽  
Red Flags ◽  
Pelvic Magnetic Resonance Imaging ◽  
Pudendal Nerve Entrapment

Pudendal neuralgia is a chronic neuropathic pelvic pain that is often misdiagnosed and inappropriately treated. The Nantes criteria provide a basis for the diagnosis of pudendal neuralgia due to pudendal nerve entrapment. The 5 essential diagnostic criteria are pain situated in the anatomical territory of the pudendal nerve, worsened by sitting, the patient is not woken at night by the pain, and no objective sensory loss is detected on clinical examination. The fifth criterion is a positive pudendal nerve block. We have also clarified a number of complementary diagnostic criteria and several exclusion criteria that make the diagnosis unlikely. When pudendal neuralgia due to pudendal nerve entrapment is diagnosed according to the Nantes criteria, no further investigation is required and medical or surgical treatment can be proposed. Nevertheless, a number of warning signs suggesting other possible causes of pudendal neuralgia must not be overlooked. These warning signs (red flags) are waking up at night, excessively neuropathic nature of the pain (for example, associated with hypoesthesia), specifically pinpointed pain, which can suggest neuroma and pain associated with neurological deficit. In these atypical presentations, the diagnosis of pain due to pudendal nerve entrapment should be reconsidered and a radiological examination should be performed. The 2 cases described in this report (tumor compression of the pudendal nerve) illustrate the need to recognize atypical pudendal neuralgia and clarify the role of pelvic magnetic resonance imaging (MRI), as MRI provides very valuable information for the evaluation of diseases involving the ischiorectal fossa. The presence of red flags must be investigated in all cases of pudendal neuralgia to avoid missing pudendal neuralgia secondary to a mechanism other than nerve entrapment. Key words: Pudendal nerve, pudendal neuralgia, Nantes criteria, pelvic pain, pudendal canal, perineal pain

scholarly journals Sacral Neuromodulation as a Treatment for Pudendal Neuralgia

2014 ◽  
Vol 5;17 (5;9) ◽  
pp. E645-E650 ◽  
Author(s):  
Assia Valovska
Keyword(s):  
Peripheral Nerve ◽  
Pelvic Pain ◽  
Nerve Stimulation ◽  
Pudendal Nerve ◽  
Peripheral Nerve Stimulation ◽  
Treatment Modalities ◽  
Pudendal Neuralgia ◽  
Nerve Stimulator ◽  
Peripheral Nerve Stimulator ◽  
Sacral Neurostimulation

Pudendal neuralgia is a debilitating pain syndrome, and finding long-lasting treatment modalities has been challenging in pain management. The pudendal nerve has sensory and motor functions, and influences autonomic functions. Thus, entrapment or damage of this nerve can have multiple serious implications. The constellation of symptoms which result from injury to this nerve is commonly referred to as pudendal neuralgia. When conservative therapy does not provide adequate pain relief and surgical procedures fail or are not viable options, central and peripheral nerve stimulation can be effective treatment modalities. More recent approaches to treatment include the use of peripheral nerve stimulation through the use of an electrical lead placed next to the pudendal nerve in the ischioanal fossa. Also, epidural stimulation of the conus medullaris and pulsed radiofrequency ablation of the pudendal nerve have been shown to be effective in small patient populations. We present the case of a 36-year-old woman who sustained pudendal nerve injury during a hysterectomy and subsequently developed intractable pelvic pain and pudendal neuralgia. Conservative treatment measures failed, but she obtained excellent results from peripheral nerve stimulator therapy. Permanent implantation consisted of 4 tined Interstim leads, individually placed into the bilateral S3 and S4 foramina. The patient has been followed for approximately 4 years since her procedure, demonstrating increased function as she is able to stand and sit for prolonged periods of time. She has returned to her usual daily activities, including horseback riding. This is the first reported case of transforminal sacral neurostimulation providing excellent relief of pudendal neuralgia related symptoms. Key words: Pudendal neuralgia, sacral neurostimulation, peripheral nerve stimulator, pelvic pain, nerve stimulation, interventional pain procedures, surgical management of pain

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