Medications and Suppositories

Talk with your doctor about all of these medications. Knowing your specific needs they may help you narrow down suggestions. Be open to trying new medications. We all know the unrelenting pain of pudendal neuralgia. Do not pass on a conservative treatment. You have nothing to lose. If something causes negative side effects or doesn't work, then you can stop taking it and try something else. If in the end nothing helps, you at least have that information and can check off medications and suppositories and let future doctors know.

There are various pharmacological options, which should be chosen in function of patient tolerance and clinical response, which might take a few trials. Amitriptyline, duloxetine, and the antiepileptics pregabalin and gabapentin are the best studied for neuropathic pain.

Oral Medications

Anticonvulsants: SNRIs ((Serotonin and Norepinephrine Reuptake Inhibitors) – are a class of antidepressant medications used to treat major depressive disorder (MDD), anxiety disorders, social phobia, chronic neuropathic pain, fibromyalgia syndrome (FMS), and menopausal symptoms. Off-label uses include treatments for attention-deficit hyperactivity disorder (ADHD), obsessive–compulsive disorder (OCD), and migraine prevention.[1] SNRIs are monoamine reuptake inhibitors; specifically, they inhibit the reuptake of serotonin and norepinephrine. These neurotransmitters are thought to play an important role in mood regulation. SNRIs can be contrasted with the selective serotonin reuptake inhibitors (SSRIs) and norepinephrine reuptake inhibitors (NRIs), which act upon single neurotransmitters:

Duloxetine/Cymbalta
pregabalin/Lyrica
Gabapentin/Neurontin
venlafaxine/Effexor
Lamotrigine/Lamictal

Tricyclics –Cyclic antidepressants ease depression by affecting chemical messengers (neurotransmitters) used to communicate between brain cells. Like most antidepressants, cyclic antidepressants work by ultimately effecting changes in brain chemistry and communication in brain nerve cell circuitry known to regulate mood, to help relieve depression.

Cyclic antidepressants block the reabsorption (reuptake) of the neurotransmitters serotonin (ser-o-TOE-nin) and norepinephrine (nor-ep-ih-NEF-rin), increasing the levels of these two neurotransmitters in the brain. Cyclic antidepressants also affect other chemical messengers, which can lead to a number of side effects.

Sometimes cyclic antidepressants are used to treat conditions other than depression, such as obsessive-compulsive disorder, anxiety disorders or nerve-related (neuropathic) pain.

Amitriptyline/Elavil
Nortriptyline/Pamelor
Doxepin/Sinequan
Amoxapine
Desipramine (Norpramin)
Imipramine (Tofranil)
Protriptyline
Trimipramine
Amitriptyline/Elavil
Nortriptyline/Pamelor
Doxepin/Sinequan

Muscle Relaxants

Baclofen
Flexeril/Cyclobenzaprine

Benzodiazepines

Be aware they are addictive (much less than opioids). Speak to your doctor.

Xanax / Alprazolam (short-acting) 2 to 4 hours.
Ativan / Lorazepam (med-acting)
Valium / Diazepam (long-acting)

Note: Ativan acts slower than Xanax, and the body removes it slower than it does Xanax.

This means that the effects of Ativan take longer to kick in but last for longer compared with those of Xanax. Because of this, people may take Ativan less frequently than Xanax.

Opioids

These are highly addictive. Meant for acute pain (broken leg, post-operative surgery pain or cancer pain, not chronic pain such as pudendal neuralgia. Your body will develop increased tolerance over time so you will need to increase your dose to get the same pain relief effect. Speak to your doctor. Opioids will make you feel great, but they are risky and dangerous to all human beings. 2, 3

Tramadol
Vicodin/Hydrocodone
Percocet/Oxycodone
Nucynta/Tapentadol
Fentanyl (patch)

Low Dose Naltrexone

Low Dose Naltrexone (LDN) – (Compounded oral medications and suppositories are not covered by insurance)

"As a daily oral therapy, LDN is inexpensive and well-tolerated. Despite initial promise of efficacy, the use of LDN for chronic disorders is still highly experimental. Published trials have low sample sizes, and few replications have been performed. We cover the typical usage of LDN in clinical trials, caveats to using the medication, and recommendations for future research and clinical work. LDN may represent one of the first glial cell modulators to be used for the management of chronic pain disorders." 1

We plan to find a doctor, hospital, or university to to conduct a large, randomized, double-blind clinical trial. It would not be experience and if the results end up showing LDN is effective and safe reducing pain due to PN, it will help the at least 200,000 people suffering from the condition in the U.S. The FDA may even approve its use thus greenlighting Medicare, Medicaid, and private insurance companies to cover LDN. Cash cost at compound pharmacy is about $35.00 a month. IF the results prove LDN is not effective treating PN, we can cross it off our list of medications, not waste money, and focus on other medications. The U.S. pain management profession needs to do this for ALL medications currently used to treat PN. For most, there is no significant medical evidence either way.

Suppository Medications

Compounded Suppositories are not covered by insurance:

Vaginal Valium
Rectal Valium
Ketamine HCl 30 mg/Diazepam 1 mg/Lidocaine HCl 30 mg Vaginal Suppository

Rectal Gel - Diastat Rectal Diazepam (Valium) Gel – 2 syringes per box - can dose either 5 mg or10 mg.

Can use two syringes (one box) per day. Covered by insurance.

Topical Medications

Topical Amitriptyline-Ketamine for treatment of rectal, genital, and perineal pain and discomfort (not sure if covered by insurance)

Topical Lidocaine (covered by insurance)

NOTE: Almost all of these medications may make you tired. The first time you use them, do so at night or on a day that you don't work and do not drive.

We need double-blind studies (with placebo) to determine which medications are most effective and which have the most and intense side effects. We feel now it's like throwing spaghetti at the wall. Doctors prescribe them and see how they work. There are many medications so it's time consuming. Most of these medications will tend to make you tired, gain weight, or even a little foggy in the brain. It depends on how well a medication reduces your pain if it's worth the side effect. We need double-blind tests on these meds.

1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3962576/

2. https://www.cdc.gov/drugoverdose/featured-topics/manage-your-pain.html

3. https://www.mayoclinic.org/chronic-pain-medication-decisions/art-20360371

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Pudendal Neuralgia Alliance

contact@pudendalneuralgiaalliance.org

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