Risk Factors and a Nomogram for Prediction of Refractory Pudendal Neuralgia: A Retrospective Multivariate Analysis Study.

BACKGROUND: Pudendal neuralgia (PN) is one of the most common forms of genital pain. About 4% or higher of patients suffering from chronic pain. OBJECTIVES: The aim of this study was to evaluate the risk factors for prediction of refractory PN (RPN). STUDY DESIGN: A retrospective multivariate analysis study. SETTING: This retrospective analysis included 112 patients with PN who received the pudendal nerve block treatment at the Pain Department of General Hospital of People's Liberation Army. METHODS: Univariate and multivariable logistic regression analyses were used for covariates selection. A nomogram was developed to estimate nonresponse to the pudendal nerve block. RESULTS: The median age of patients and duration of patients were 48.0 and 1.25 years, respectively. Among 112 patients, there were 64 good responders to the pudendal nerve block for neuropathic pain and 48 nonresponders. Multivariate analysis of 112 patients with PN demonstrated high self-rating depression scale scores (> 32) (odds ratio [OR], 95% confidence interval [CI]: 0.11, 0.01-0.77), damage to more than 2 terminal branches (OR, 95% CI: 0.22, 0.07-0.71), sensory deficit at S2-S4 on the dermatome map (OR, 95% CI: 0.22, 0.05-0.90), and duration of pain (> 4 years) (OR, 95% CI: 0.10, 0.03-0.42) were significant prognostic factors for nonresponse to the pudendal nerve block. LIMITATIONS: There are information biases for retrospective analysis, thus making it more difficult to come up with definitive conclusions. Large-scale randomized clinical trials are warranted to evaluate the risk factors for prediction of RPN. CONCLUSIONS: A longer duration of pain was correlated with a worse prognosis of the neurological disease. Patients with depression were prone to nonresponse to the pudendal nerve block treatment. Pain involved in more than 2 terminal branches and small fibers, affected at S2-S4 dermatome map, were considered to poor prognosis.

Sacral Nerve Stimulation in Patients With Refractory Pudendal Neuralgia.

BACKGROUND: Pudendal neuralgia (PN) is one of the most common forms of genital pain. Only 42.2% of PN patients respond to the first-line treatment. Novel neuromodulation techniques in the treatment of refractory PN patients are urgently required. OBJECTIVES: The aim of this study was to evaluate the treatment effects and adverse events of sacral nerve stimulation (SNS) for patients with refractory PN. STUDY DESIGN: A prospective nonrandomized study. SETTING: This prospective analysis included 33 patients who received the phase II surgical implantation. METHODS: A total of 55 eligible PN patients were recruited for SNS treatment after informed consent, and 33 of 55 patients with a minimum 50% improvement were candidates for surgical implantation. Visual Analog Scale (VAS) scores, Self-rating Anxiety and Depression Scale, Quality of life score (SF-36), and sleep monitoring indicators before and after surgery were used to assess the effects of SNS on patients with refractory PN. RESULTS: Thirty-three patients were included in the final analysis, involving 24 women and 9 men with a mean age of 49.5 years (26-70 years). There was a favorable decrease in pain severity (VAS scores) from 7.1 ± 1.1 at baseline to 6.1 ± 1.0 on postoperative day 1, and 2.8 ± 0.7 at 1 week, 1.7 ± 0.5 at 1 month, 1.1 ± 0.7 at 6 months, and 1.0 ± 0.6 at 12 months after surgery, respectively (P < 0.05). The mean score of each section of SF-36 after SNS was significantly higher than that at baseline (P < 0.05). Total sleep time and sleep time in each period were significantly prolonged after SNS implantation compared with that before surgery (6 months vs Pre, total: 5.32 ± 1.49 hours vs 3.66 ± 1.19 hours, deep: 2.52 ± 0.63 hours vs 1.36 ± 0.43 hours, light: 1.78 ± 0.42 hours vs 0.99 ± 0.30 hours, rapid eye movement: 1.41 ± 0.29 hours vs 0.89 ± 0.27 hours, P < 0.05). No serious device complications were reported during the follow-up period. LIMITATIONS: Large-scale randomized clinical trials are warranted to evaluate the risk factors for prediction of refractory PN. CONCLUSIONS: These data imply that SNS can have beneficial effects on patients with refractory PN.

The application of pudendal nerve blockade in the treatment of pudendal neuralgia related chronic pelvic pain / Nervus pudendus idegblokád alkalmazása krónikus kismedencei fájdalmat okozó pudendusneuralgia kezelésében

Pudendal neuralgia is a rare and ­ in the absence of somatic, radiological and laboratory abnormalities ­ often unrec-ognizable problem, posing a serious challenge to therapeutic management. Our case study presents the complete diagnostic and therapeutic algorithm of a female patient with chronic pudendal pain. In addition, our paper draws attention to the role of pelvic pain workgroups ­ such as the Pelvic Pain Task Force of the Semmelweis University ­ where cases of chronic pelvic pain with no clear medical reason can be assessed and treated with higher efficiency.

When and How to Utilize Pudendal Nerve Blocks for Treatment of Pudendal Neuralgia.

Chronic pelvic pain is a common cause of pain in reproductive age women with debilitating consequences for affected women's health and quality of life. Treatment providers must be well versed in all treatment options for these patients, understanding the overlap in the management and treatment of chronic pelvic pain caused by pudendal neuralgia, myofascial pelvic pain, and vulvodynia. Pudendal blocks are a simple and quick procedure that can be performed in the office and often helps improve all the above conditions when used along with other treatment options. We review the anatomy and methodology on when and how to perform pudendal blocks in the office to better inform the general gynecologist on how to implement offering this treatment in the outpatient clinical setting.

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

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 CT-guided 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.

The drug-resistant pudendal neuralgia management: A systematic review.

AIMS: Pudendal neuralgia (PN) due to pudendal nerve entrapment is a well-known disease in medical community but both diagnostic and treatment may be delayed for patients. The goal of this study was to achieve a systematic review of the published treatments of PN in order to help physician to take their decision to treat PN. METHODS: A Systematic review based on MEDLINE, Embase, and Cochrane databases was performed to identify articles related to PN. Studies involving ≥ 10 patients presenting PN according to Nantes's criteria who were managed with an intervention for their pain were reviewed. Data were extracted manually for qualitative analysis. RESULTS: Fifteen studies involving 672 patients (mean age 53.2 +/-5.1, SD 95%) were included. Nine different types of treatments were evaluated. Effectiveness of the treatments was heterogeneously assessed. Pain improvement was achieved in 41% to 100%, 13.4% to 100%, 60% to 100%, 12.2% to 100% in immediate, 3-month, 6-month, and 1-year post procedure, respectively. Complications reported were all grade ≤ II of Dindo-Clavien classification's. Given the heterogeneity of the outcomes measures and the lack of homogeneous prospective studies, no recommendation could be established to choose in between treatments. Methodological quality of the studies was heterogeneous. CONCLUSION: Many treatments seems available for drug-resistant PN. Given the heterogeneity of the outcomes measures and the lack of homogeneous prospective studies, no recommendation could be established to determine the best management strategy. Further studies about PN management are needed and should have common endpoint and follow-up.

Dual Site Pudendal Nerve Infiltration: More than Just a Diagnostic Test?

BACKGROUND: Pudendal neuralgia (PN) is a very painful and often disabling condition in which pudendal nerve blocks play an important role in both the diagnosis and management of PN. Some previous reports have advocated the use of pudendal nerve infiltration (PNI) as a diagnostic test only. OBJECTIVE: We aim to assess the outcomes of patients with typical refractory PN who underwent dual site computed tomography (CT)-guided pudendal nerve infiltration. STUDY DESIGN: A bicentric, retrospective cohort analysis. SETTING: An academic practice. METHODS: Between 2002 and 2016, 385 PNIs were performed in 195 patients in the 2 units. Only patients suffering from typical clinical PN were included, and only the first infiltration in each patient was considered for analysis. Therefore, 95 patients who underwent 155 procedures were assessed. Pain was assessed using a visual analog scale (0-10) and self-reported estimated improvement (SRI), expressed as a percentage. Efficacy of the procedure was assessed at 1, 3, and 6 months after procedure follow-up, and clinical success was defined as a 50% decrease of the VAS score. All procedures were performed under CT guidance and on an outpatient basis. Dual site infiltration was performed in each case at both the ischial spine and intra-Alcock's canal sites using a mixture of fast- and slow-acting anesthetic (1 mL lidocaine hydrochloride 1% and 2 mL ropivacaine chlorhydrate) along with a half dose of 1.5 mL of cortivazol (3.75 mg). RESULTS: Clinical success at one month post-procedure was present in 63.2% of patients (60/95) with a mean VAS score of 2.07 (P < 0.05) and a mean SRI of 71%. At 3 months follow-up, clinical success was still present in 50.5% of patients (48/95) with a mean VAS score of 2.90/10 (P < 0.05) and a mean SRI of 62.3%. At 6 months follow-up, the efficacy rate decreased to 25.2% with a mean VAS score of 3.2/10 and SRI of 60%. LIMITATIONS: The retrospective aspect of the study is a limitation, as well as the lack of a control group. CONCLUSION: Dual site PNI under CT guidance may offer significant mid-term pain relief to a majority of patients suffering from typical refractory PN. KEY WORDS: Pudendal nerve, neuralgia, block, Alcock, CT, guidance.

Measuring the Quality of Pudendal Nerve Perineural Injections.

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.

Bloqueo caudal epidural para el tratamiento del síndrome de atrapamiento del nervio pudendo / Caudal epidural blockade for treating pudendal nerve entrapment syndrome

Introducción: el síndrome de atrapamiento del nervio pudendo es generalmente desconocido y suele ser mal diagnosticado o confundido con otras enfermedades. Lo describió por primera vez Amarenco en 1987. La manifestación clínica clásica es la neuralgia del pudendo, un dolor neuropático del área genital. Objetivo: describir la evolución clínica satisfactoria de una paciente con dolor neuropático por atrapamiento del nervio pudendo, al realizarle un bloqueo caudal epidural, complementado con tratamiento farmacológico. Presentación del caso: paciente femenina de 38 años con antecedentes de salud, que después del parto vaginal comenzó a presentar dolor neuropático en región anal y perineal, para el cual recibió varios tratamientos, sin resultados satisfactorios, con una evolución de 5 años. Se realizó bloqueo caudal epidural, bajo conducción ultrasonográfica, hasta situar la punta de la aguja a nivel de S2, se administró 1 mL de triamcinolona acetónido y 1 mL de bupivacaína al 0.25 por ciento, esto se realizó en tres ocasiones con intervalos de 1 semana, además se medicó por vía oral después del tercer bloqueo, con amitriptilina, gabapentina y baclofeno, por un periodo de 3 meses. Resultados: la mejoría clínica fue evidente a la semana de iniciado el tratamiento y posterior a la cuarta semana la paciente se encontraba libre de dolor. Conclusiones: el bloqueo caudal epidural unido al uso de medicamentos por vía oral es efectivo para el tratamiento del SANP(AU)

Introduction: Pudendal nerve entrapment (PNE) is generally unknown syndrome and usually not well-diagnosed, or it is confused with other illnesses. It was first described by Amarenco in 1987. The classic clinical manifestation is pudendal nerve neuralgia, a neuropathic pain in the genital area. Objective: Present the satisfactory clinical evolution of a female patient with neuropathic pain due to entrapment of her pudendal nerve, after being performed a caudal block, supplemented with pharmacological treatment. Case report: A 38-year-old healthy female patient who began presenting neuropathic pain in her anal and vaginal areas after natural childbirth. She received several treatments, without satisfactory results in a 5-year evolution. It was decided to perform a caudal block, with ultrasonographic guidance, until locating the needle tip to S2 level. 1 mL of triamcinolone acetonide and 1 mL of bupivacaine-0.25 percent were then administered. this was performed in three occasions in one-week intervals; after the third blockade, amitriptyline, gabapentin and baclofen for three months were also prescribed as oral medication.Results: Clinical improvement was evident a week after the treatment was started; and the patient was painless after the fourth week. Conclusions: caudal block together with oral medications proved effective in PNE treatment(AU)

Response to pudendal nerve block in women with pudendal neuralgia.

OBJECTIVE: To examine the evolution of pain and the duration of numbness after neural blockade of the pudendal nerve in women with pudendal neuralgia and correlate with clinical and historical data. DESIGN: Prospective, single arm, open label study. SETTING: University hospital and outpatient clinic. SUBJECTS: Eighty-two adult female patients were recruited from November 8, 2008 to February 14, 2010. Patients were selected based on the presence of spontaneous or provoked pain in the distribution of the pudendal nerve. INTERVENTIONS: Subjects underwent a standardized pudendal nerve block. OUTCOME MEASURES: Visual analog pain scores and the presence of numbness were recorded before and for 64 hours after the pudendal nerve block. A complete clinical history and examination were documented. RESULTS: Sixty-six patients completed the study. About 86.9% had a reduction in one or more pain symptom, while 44.3% found that more than one of their pain symptoms did not return. About 69.7% of patients reported numbness lasting up to 16 hours or longer. Previous gynecological surgery was recorded in 75.8%, previous traumatic obstetric events in 47.0% of cases. Prolonged history of pain correlated with a reduced chance of positive outcome of the pudendal nerve block. CONCLUSION: In patients with pudendal neuralgia, the pudendal nerve block has a variable response, but may have a beneficial effect in a subset of women. Surgical and obstetrical trauma are common historical antecedents.

Pudendal neuralgia following transobturator inside-out tape procedure (TVT-O)--case report and anatomical study.

Persistent pain after TVT-O procedure is a rare complication. Nerve injuries have been suspected as a cause of persistent pain. We present one case of atypical postoperative pain--pudendal neuralgia following TVT-O procedure--which persisted 3 years after the primary procedure. The patient required surgical removal of the tape, which brought only partial relief. Complete relief from pain was afterwards achieved with repeated local applications of anesthetics with corticosteroids. The recurrent stress urinary incontinence was treated with retropubic TVT. Pudendal nerve irritation was also described after retropubic sling procedure, and the cadaveric dissection indicated the theoretic possibility of nerve injury during retropubic sling procedure. To explain the mechanism of nerve injury, we performed cadaveric dissections on a formalin-embalmed female body. We were able to demonstrate the contact of the needle with the pudendal nerve after aberrant passage of the inserter.