A pudendal nerve block is the clinical method utilized for the diagnosis of pudendal neuralgia (PN). It is one of the five criteria defined in The Nantes criteria.

 

It is not a treatment for PN as the anesthetic (Bupivacaine) only lasts four to eight hours. It is the same when a dentist gives you an injection of lidocaine before dental work or a physician gives you a nerve block post-op to reduce your pain for a few hours before you can get home. ALL anesthetics wear off and do not treat the cause of pain. They temporarily block it.

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Regrettably, there are currently doctors and pelvic rehabilitation businesses who charge cash claiming a PN block is a treatment for pudendal neuralgia. Do not throw away your money. Also, it is not a good thing to have injection after injection that serves no purpose so close to the pudendal nerve as it could cause irritation and more pain.

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There are four approaches to the PN block. We highly recommend the Transgluteal Approach. However, talk to your doctor and friends with PN before making a decision. Always remember to get a second opinion from other doctor if you don't feel comfortable or aren't sure of the first doctor's recommendation. We will list the other three, the Transvaginal, Transperienal, and Perirectal descriptions below after the Transgluteal.

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Advantages to the Transgluteal Approach over the others:

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1. Ultrasound guidance ensures accurate needle placement. A fluoroscopy is faster but releases enough radiation to cause cancer later in life. Research before you allow a doctor to use and discuss.

2. Avoids needle insertion into the high concentration of nerve endings in the vagina, perineum, and rectum and should be painless when done by an experienced doctor. We do not have nearly as many nerves in our bottoms as we do in our vaginas and/or rectums.

3. Can be used for both women and men.

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The Transgluteal Approach Procedure

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Always ask questions before a procedure:

   1.  What to except during the procedure

   2.  What medications will the doctor be using and what is the purpose of each. It's your body. Know what the doctor    
        is injecting into you and what each medication does.  It's your body and you only have one.

 

Generally, the patient is fully awake. The procedure should be painless with an experienced doctor. The physician will want you to be fully conscious and aware of how much the block reduces or does not reduce your pain.

 

However, depending on other conditions you may have, they may choose to administer light sedation, but we highly suggest no sedation so you can feel the full effect of the

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The patient is placed in a prone position (on stomach) with a face down pillow. You will be looking at the floor. It is important to to know this before you walk into the surgery room because most people will expect to be on their backs and  it is a vulnerable position any many of us expect to be on our backs and are surprised.  This approach can be painless however if done but an expert doctor. The procedure should only take up to 30 minutes, probably less time, from when you walk into the surgical room.  It is always a good idea to bring someone for support if you can even though the procedure is short and simple. No one likes the idea of a needle and there can be a bit of numbness in the leg sometimes, but not usually.

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The patient's skin is prepared with iodine and surgically draped. The doctor injects 1% buffered Lidocaine to anesthetize surface and subcutaneous skin.

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A 22-gauge needle (small) is introduced. The higher the number, the thinner the needle. For example, to inject a neurostimulator lead, doctors generally use a 13-gauge (large) needle to insert a peripheral nerve stimulator lead.

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It is directed under ultrasound guide laterally to medial approach at the level of the ischial spine (a boney prominence) to find exact anatomical placement of the injection alongside the pudenda! nerve before dividing into three branches in this order: Rectal nerve, Perineal nerve, Dorsal nerve of the clitoris/penis.

 

This is a one-day outpatient procedure. You should discover your result during the next few hours. 

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If the doctor tells you that you will not know the result for two weeks, they have injected you with a steroid. Confirm with the doctor that they at least used the proper medication, Bupivacaine, for the block. The steroid cannot be undone and should have nothing to do with this purely diagnostic block.

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The doctor should use the following three medication injections:

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   1.   1% Lidocaine (short-lasting anesthetic to numb surface area).

   2.   A Contrast such as Omnipaque 1 ml to see ischial spine to locate the pudendal nerve.
           (There are other contrast agents such as  Lopamidol. It doesn't matter which your doctor uses, just so they
            use one to locate the pudendal nerve)

   3.   0.25% Bupivacaine (Marcaine) 4 cc (doctor can choose to use more) is a long-lasting anesthetic 4-8 hours.

         This is the anesthetic BLOCK.

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You may feel the block within 5 minutes which means your pudendal nerve will go numb/pain free or at least more that 50%. The higher the percentage of pain relief the more the chance that the positive diagnosis is accurate. It takes 30 minutes for the Bupivacaine to take full effect.   

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STEROIDS

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No steroids should be used per double-blind study above published in Nantes eight years ago in 2016.  Steroids injections are effective for many conditions but not pudendal neuralgia, such as:

• Rheumatoid arthritis

• Psoriatic arthritis

• Gout

• Back pain

• Inflamed bursae (bursitis)

• Inflamed tendons near your shoulder, elbow, hip, knee, hand, or wrist (tendinitis)

 

Even for these conditions, the use of steroids must be limited to protect your body from injury. They carry risk  Most healthcare providers recommend getting a cortisone shot no more than three times a year in a single joint, and no more than six times a year in total. They typically also recommend spacing out each injection by at least 12 weeks. 2

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Regrettably, there are currently doctors and pelvic rehabilitation businesses who charge cash claiming as many as six cortisone shots, once a week, for six weeks, treats pudendal neuralgia. This is medical unethical. Do research and protect your body. Remember, many doctors and pelvic rehabilitation businesses, especially those who accept only cash and not insurance, often do completely ineffective and with steroids, dangerous, injections and treatments promising you the moon and taking your money. Save it for scientifically-based treatments.

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Also, steroids always carry risk, can irritate pudendal nerve. If doctor insists, print out study. If doctor still insists, find another.  We must all advocate for and project our bodies. Physicians are as fallible as any person. Regrettably, most pain management doctors do not learn about pudendal neuralgia and if they do, they don't read current scientific publications about pudendal neuralgia or continue their education about the condition. Most think this is a "waste of time" as they will not see many patients who suffer from PN during their practice. If a doctor doesn't want to educate themselves about PN, they should not treat it. This of course goes for any condition or disease a physician doesn't want to fully study.

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Steroid Use Refuted: The 2016 Nantes France double-blind medical study of the therapeutic effect of including a

steroid in the PN block concluded that corticosteroids provide "no therapeutic benefits & should no longer be used." 1

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The patient will stay in the recovery area for 30 minutes to ensure no leg numbness. They should NOT rest or nap after returning home. Patient must be active & attempt to trigger the usual pain. This will determine (diagnose) if the area (pudendal nerve) injected is the one causing your pain. Track pain/pain relief in the provided pain diary for the next 6 hours. Bring to the next appointment.

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Results

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Positive, Negative, or Inconclusive

• > 51% pain relief for 4-8 hours: You have pudendaI neuralgia if you also have the other four criteria

• < 51% pain relief for 4-8 hours: You do not have pudendaI neuralgia. There is another another condition causing

       your pain.

• Inconclusive: Try one more block to be sure.

 

You may want to see another doctor. A second opinion is invaluable and not all doctors are equally qualified in technique or spend the time necessary to learn how to perform the procedure correctly.

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If your doctor tells you that it will take one to two weeks for full results, they have injected you with a steroid. Make sure to ask what is being injected into your body at for any reason before the injection.

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Other Approaches

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Transvaginal approach: The doctor will use his fingers to feel for the ischial spine along the walls of the vagina to locate the pudendal nerve. The provider inserts a needle guide device into your vagina called an Iowa Trumpet then the needle with the BLOCK injection. Many women find this painful.

It can be difficult to differentiate the pain of the injection from the pain of pudendal neuralgia. prepped. The vaginal approach

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The Transperineal Approach: The patient, man or woman, is placed in the lithotomy position (leg stirrups). The provider will clean the skin on your perineum with an antiseptic solution. The doctor will insert his finger into your rectum or vagina to feel for your ischial spine to locate your pudendal nerve. Patients often feel pain at the injection of the skin of the perineum. It can be difficult to differentiate the pain of the injection from the pain of pudendal neuralgia.

 

The Perirectal Approach: The patient, man or woman: Using a nerve stimulator to elicit contractions of the external anal sphincter. The patient is positioned in a recumbent position. The skin is prepped. The clinician's index finger will be inserted into the rectum to palpate the ischial spine. The needle is advanced lateral to the rectum and the clinician's finger in the posterolateral direction until it reaches the ischial spine. Injection directly into the sacrospinous ligament near its ischial insertion before advancing the spinal needle to its final position is optional. The needle is then advanced through the sacrospinous ligament medial and inferior to the ischial spine.

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1 2016 The Authors BJOG An International Journal of Obstetrics and Genecology published by John Wiley & Sons Ltd on behalf of Royal College of Obstetricians and Gynecologists. LINK https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5215631/

2 https://www.verywellhealth.com/how-many-cortisone-shots-can-i-have-2549573

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Pudendal Neuralgia Alliance

contact@pudendalneuralgiaalliance.org

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