Pudendal Neuropathy

Pudendal Neuropathy Pudendal Neuropathy as an Etiology of as an Etiology of

Chronic Perineal Pain: Chronic Perineal Pain: Diagnosis and Diagnosis and

TreatmentTreatmentCharles Popeney, Van Ansell, Ken Charles Popeney, Van Ansell, Ken RenneyRenney

Fort Bend NeurologyFort Bend NeurologyFoundation Surgical HospitalFoundation Surgical HospitalHouston Orthopedic Sports Houston Orthopedic Sports Medicine AssociateMedicine Associate

Study ObjectiveStudy Objective

To illustrate the diagnosis of To illustrate the diagnosis of pudendal neuropathy as an etiology pudendal neuropathy as an etiology of chronic perineal pain. This study of chronic perineal pain. This study analyzes a diagnostic protocol for analyzes a diagnostic protocol for pudendal neuropathy as well as pudendal neuropathy as well as clinical response to surgical clinical response to surgical decompression.decompression.

ParticipantsParticipants

58 patients having had surgical 58 patients having had surgical decompressiondecompression

Diagnosed with unilateral or Diagnosed with unilateral or bilateral pudendal neuropathybilateral pudendal neuropathy

Retrospective StudyRetrospective Study

Main Features for Main Features for DiagnosisDiagnosis

Chronic, progressive burning pain in Chronic, progressive burning pain in the perineum (ano-rectal and/or the perineum (ano-rectal and/or urogenital) that was worse with urogenital) that was worse with sittingsitting

Included pain in testicles, penis, or Included pain in testicles, penis, or rectum in malesrectum in males

Included pain in the labia, clitoris, Included pain in the labia, clitoris, and rectum in femalesand rectum in females

Location of PainLocation of Pain

MalesMales FemalesFemales

Perineum Perineum 83.87%83.87%

Perineum Perineum 75.00%75.00%

Testicles Testicles 67.74%67.74%

Labia Labia 37.50%37.50%

Penis Penis 29.03%29.03%

Clitoris Clitoris 33.33%33.33%

Rectum Rectum 38.71%38.71%

Rectum Rectum 70.83%70.83%

Additional FeaturesAdditional Features

Urinary hesitancy, frequency and Urinary hesitancy, frequency and urgency (40%)urgency (40%)

Constipation (29%) including painful Constipation (29%) including painful bowel movementsbowel movements

Sexual dysfunction (33%)Sexual dysfunction (33%)

Prior DiagnosisPrior Diagnosis Interstitial Cystitis (30%)Interstitial Cystitis (30%) Vulvadynia (50%)Vulvadynia (50%) Endometriosis (13%)Endometriosis (13%) Prostatitis or epidymitis (63%)Prostatitis or epidymitis (63%) Piriformis Syndrome (20%)Piriformis Syndrome (20%) Levator Ani Syndrome (3%)Levator Ani Syndrome (3%) Coccydynia (6%)Coccydynia (6%) Lumbosacral Radiculopathy (3%)Lumbosacral Radiculopathy (3%) Chronic Pelvic Pain Syndrome (20%)Chronic Pelvic Pain Syndrome (20%)

Patient ProfilePatient Profile Had seen multiple physiciansHad seen multiple physicians Failed multiple pharmacologic treatmentsFailed multiple pharmacologic treatments Failed physiotherapy and perineal Failed physiotherapy and perineal

hyperprotectionhyperprotection Severely disabled by painSeverely disabled by pain No evidence of organ disease (negative No evidence of organ disease (negative

work up for prostatitis, epidymitis, work up for prostatitis, epidymitis, negative scans of pelvic and lumbosacral negative scans of pelvic and lumbosacral spine, normal colorectal evaluation and spine, normal colorectal evaluation and laparoscopylaparoscopy

Disabling SymptomsDisabling Symptoms

Average VAS Before Surgery: 6.06 Range (2-10)Average VAS Before Surgery: 6.06 Range (2-10)Question (before surgery): If you were to spend Question (before surgery): If you were to spend

the rest of your life with your symptoms just the rest of your life with your symptoms just the way they have been during the last week, the way they have been during the last week, how would you feel about that?how would you feel about that?

---- 86.21% of patients answered Terrible or ---- 86.21% of patients answered Terrible or UnhappyUnhappy

Question (before surgery): How much have your Question (before surgery): How much have your symptoms kept you from doing the kinds of symptoms kept you from doing the kinds of things you would usually do over the last things you would usually do over the last month?month?

---- 72.41% of patients answered A lot---- 72.41% of patients answered A lot

Diagnostic CriteriaDiagnostic Criteria

Burning pain in distribution of the Burning pain in distribution of the pudendal nerve that was aggravated pudendal nerve that was aggravated with sitting with or without voiding, with sitting with or without voiding, erectile, or rectal dysfunction erectile, or rectal dysfunction without evidence of organ diseasewithout evidence of organ disease

These patients all had positive These patients all had positive diagnostic blocks that reduced their diagnostic blocks that reduced their pain or prolonged pudendal distal pain or prolonged pudendal distal motor latenciesmotor latencies

Pudendal Nerve BlocksPudendal Nerve Blocks

All patients, same physicianAll patients, same physician First 2 blocks bilateral ischial spineFirst 2 blocks bilateral ischial spine 33rdrd block Alcock’s canal block Alcock’s canal Depomedrol 40 mg, 5cc of 1% Depomedrol 40 mg, 5cc of 1%

LidocaineLidocaine Anesthetic response assessed by Anesthetic response assessed by

VAS before and shortly after block VAS before and shortly after block while sitting on hard benchwhile sitting on hard bench

Pudendal Nerve Distal Pudendal Nerve Distal Motor LatencyMotor Latency

All patients, same physicianAll patients, same physician Bilateral PNMLT and EMGBilateral PNMLT and EMG Normal Latency < 4 msNormal Latency < 4 ms Acute and chronic Acute and chronic

denervation/reinnervation during denervation/reinnervation during EMG EMG

Indications for SurgeryIndications for Surgery

Diagnosis of Pudendal Neuropathy Diagnosis of Pudendal Neuropathy per protocolper protocol

Failed conservative treatmentFailed conservative treatment No lasting improvement for steroid No lasting improvement for steroid

effect of pudendal blockeffect of pudendal block

Surgical Exploration and Surgical Exploration and ReleaseRelease

Section Sacrotuberous Section Sacrotuberous ligamentligament

~ Explore Proximal ~ Explore Proximal NerveNerve

Incise Alcock’s CanalIncise Alcock’s Canal Section Sacrospinous Section Sacrospinous

ligamentligament Transpose pudendal Transpose pudendal

nervenerve

Common Surgical Common Surgical FindingsFindings

Hypertrophic ligamentsHypertrophic ligaments Conjoined ligamentsConjoined ligaments AdhesionsAdhesions Proximal branchingProximal branching Branch penetrating SSLBranch penetrating SSL Thickened obturator Thickened obturator

fasciafascia Elongated ischial spineElongated ischial spine

Post-op SurveysPost-op Surveys

58 patients were independently assessed 58 patients were independently assessed in an uncontrolled retrospective in an uncontrolled retrospective consecutive case series by 1 year post-op consecutive case series by 1 year post-op surveyssurveys

Degree of pain was assessed by pre and Degree of pain was assessed by pre and post op VAS Score, % global overall post op VAS Score, % global overall improvement, and improved function and improvement, and improved function and quality of life as assessed by NIH-CPSI quality of life as assessed by NIH-CPSI questions.questions.

Morbidity QuestionsMorbidity Questions

Post-op QuestionnairePost-op Questionnaire When was your surgery?When was your surgery? From month to month following surgery, has your pain been decreasing? If so, what is your overall percent From month to month following surgery, has your pain been decreasing? If so, what is your overall percent

improvement?improvement? How often have you had pain or discomfort in any of the previously afflicted areas since surgery?How often have you had pain or discomfort in any of the previously afflicted areas since surgery?

a. Never a. Never (score = 4)(score = 4)b. Rarelyb. Rarely (score = 10/3)(score = 10/3)c. Sometimesc. Sometimes (score = 8/3)(score = 8/3)d. Oftend. Often (score = 2)(score = 2)e. Usuallye. Usually (score = 4/3)(score = 4/3)f. Alwaysf. Always (score = 2/3)(score = 2/3)

Which number best describes your average pain or discomfort on the days you had it since surgery?Which number best describes your average pain or discomfort on the days you had it since surgery?VAS 1-10VAS 1-10

How much have your symptoms kept you from doing the kinds of things you would usually do, since surgery?How much have your symptoms kept you from doing the kinds of things you would usually do, since surgery?a. Nonea. None (score = 4)(score = 4)b. Only a littleb. Only a little (score = 3)(score = 3)c. Somec. Some (score = 2)(score = 2)d. A lotd. A lot (score = 1)(score = 1)

How much do you think about your symptoms since surgery?How much do you think about your symptoms since surgery?a. Nonea. None (score = 4)(score = 4)b. Only a littleb. Only a little (score = 3)(score = 3)c. Somec. Some (score = 2)(score = 2)d. A lotd. A lot (score = 1)(score = 1)

If you were to spend the rest of your life with your symptoms just the way they have been since surgery, how If you were to spend the rest of your life with your symptoms just the way they have been since surgery, how would you feel?would you feel?

a. Delighteda. Delighted (score = 4) (score = 4)b. Pleasedb. Pleased (score = 3.5) (score = 3.5)c. Mostly satisfiedc. Mostly satisfied (score = 3) (score = 3)d. Mixedd. Mixed (score = 2.5) (score = 2.5)e. Mostly dissatisfiede. Mostly dissatisfied (score = 2) (score = 2)f. Unhappyf. Unhappy (score = 1.5) (score = 1.5)g. Terribleg. Terrible (score = 1) (score = 1)

Are you still on daily medications for your pain? If so, which ones? Have you been able to decrease the dosages?Are you still on daily medications for your pain? If so, which ones? Have you been able to decrease the dosages? Do you have any bowel, bladder incontinence or other problems?Do you have any bowel, bladder incontinence or other problems? Do you have any areas of numbness related to the surgery?Do you have any areas of numbness related to the surgery? Have you been diagnosed with SI joint, hip or lower back problems as a result of surgery?Have you been diagnosed with SI joint, hip or lower back problems as a result of surgery? Besides pain improvement, have any other problems improved since surgery?, i..e. sexual, urinary etc.Besides pain improvement, have any other problems improved since surgery?, i..e. sexual, urinary etc. How long did it take to get back to most of your regular activities?How long did it take to get back to most of your regular activities?

Patient DemographicsPatient DemographicsFeatureFeature Study GroupStudy Group

(N=58)(N=58)

Patient CharacteristicsPatient Characteristics

SexSex

FemaleFemale

MaleMale

Age- yearsAge- years

Mean (Range)Mean (Range)

Time with symptoms before Time with symptoms before surgery-monthssurgery-months


Motor Latency Distal Pudendal Motor Latency Distal Pudendal Nerve- msNerve- ms


26 (44.83)26 (44.83)

32 (55.17)32 (55.17)

45.71 (21-78)(stdev=11.843)45.71 (21-78)(stdev=11.843)

47.38 (1-180)(stdev=47.553)47.38 (1-180)(stdev=47.553)

3.26 (.90-9.80)(stdev=1.711, 3.26 (.90-9.80)(stdev=1.711, n=116)n=116)

* Values are number (percentage) unless otherwise indicated

Defining RespondersDefining Responders

Reduction of VAS Score by 50% or Reduction of VAS Score by 50% or more more oror

Greater than 50% Global overall Greater than 50% Global overall improvement improvement oror

Increase by 50% in NIH-CPSI Increase by 50% in NIH-CPSI function/quality questionsfunction/quality questions

ResultsResults

FeatureFeature Study GroupStudy Group

(N=58)(N=58)

RespondersResponders 35 (60.34)35 (60.34)

SexSex

FemaleFemale

MaleMale







14 (40)14 (40)

21 (60)21 (60)

45.77 (21-78)45.77 (21-78)(stdev=12.696)(stdev=12.696)

43.49 (1-180)43.49 (1-180)(stdev=48.598)(stdev=48.598)

3.28 (.90-9.80)3.28 (.90-9.80)(stdev=1.788, n=70)(stdev=1.788, n=70)


Results cont.Results cont.

FeatureFeature Study GroupStudy Group

(N=58)(N=58)

NonrespondersNonresponders 23 (39.66)23 (39.66)

SexSex

FemaleFemale

MaleMale







12 (52.17)12 (52.17)

11 (47.83)11 (47.83)

45.61 (25-62)45.61 (25-62)(stdev=10.689)(stdev=10.689)

53.30 (8-156)53.30 (8-156)(stdev=46.345)(stdev=46.345)

3.23 (1-8.30)(stdev=1.606, 3.23 (1-8.30)(stdev=1.606, n=46)n=46)


MorbidityMorbidity

Urinary incontinence 1 (1.2%)Urinary incontinence 1 (1.2%) Numbness in small patch of the Numbness in small patch of the

pudendal nerve (vaginal, rectal, pudendal nerve (vaginal, rectal, perineum areas) 7 (12%)perineum areas) 7 (12%)

S.I. joint dysfunction 5 (8.6%)S.I. joint dysfunction 5 (8.6%)

Responder/Nonresponder Responder/Nonresponder AnalysisAnalysis

AgeAge GenderGender Duration of symptomsDuration of symptoms Degree of prolonged distal latencyDegree of prolonged distal latency

Conclusion: Did not predict failure or Conclusion: Did not predict failure or success of success of surgical outcome surgical outcome

The FutureThe Future Further neurophysiologyFurther neurophysiology BCRBCR QSTQST Further intraoperative monitoringFurther intraoperative monitoring

- reducing morbidity- reducing morbidity- ? improved perisurgical latencies- ? improved perisurgical latencies

Continued look at non-respondersContinued look at non-responders Continued care for non-respondersContinued care for non-responders

- Botox- Botox- Sacral Modulation- Sacral Modulation

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Pudendal Neuropathy