NOTE Disability: Including this publication except along with link to full article could be useful in applying for Disability as most U.S. doctors who review your claim will be unfamiliar with the condition, it's severity, and seriousness. I would not print the entire article as it's quite long but if you see anything else that would specifically help your case, include it in the printout.

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Pudendal Neuralgia

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Stephen W. Leslie; Stanley Antolak; Michael P. Feloney; Taylor L. Soon-Sutton.

Author Information and Affiliations

Last Update: February 12, 2024.

LINK to full publication: https://www.ncbi.nlm.nih.gov/books/NBK562246/#:~:text=Pudendal%20neuralgia%20is%20the%20neuropathic,intense%2C%20chronic%2C%20debilitating%20pain.

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Continuing Education Activity

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Pudendal neuralgia is a chronic pelvic and perineal pain syndrome originating from damage, injury, inflammation, or irritation of the pudendal nerve. The condition is primarily a clinical diagnosis that is suggested by characteristic features, sometimes referred to as the "Nantes" criteria. Treatment is analogous to carpal tunnel syndrome, including initial conservative nerve protection measures, physical therapy, pharmacologic therapy, pudendal nerve blocks, sacral neuromodulation, and surgical decompression of the pudendal nerves. Few clinicians examine patients specifically for pudendal neuralgia [especially in the U.S.] or focus on common morphologic or infectious causes, resulting in delayed diagnosis and treatment.

 

This delay often leads to negative consequences, such as inadequate pain control with subsequent patient frustration and depression. Adverse effects on cognitive, behavioral, sexual, emotional, and psychosocial health may also occur. Patients with chronic pelvic or perineal pain who are initially diagnosed with other conditions but fail to respond to standard therapy should be reevaluated for possible pudendal neuralgia, as the treatment protocol is generally completely different. This activity outlines the proper diagnostic evaluation and management of pudendal neuralgia, as well as reviewing the role of the interprofessional team in improving care and outcomes for patients with this uncommon but potentially debilitating disorder.

Objectives:

• Identify the etiology and types of pudendal neuralgia.

• Identify the appropriate steps in the evaluation of pudendal neuralgia.

• Identify the management options available for pudendal neuralgia.

• Strategize how the interprofessional team enhances care coordination and communication advances
  multidisciplinary pudendal neuralgia treatment and improves outcomes.

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Introduction

Pudendal neuralgia is the neuropathic pain component of the syndrome caused by pudendal nerve entrapment and neuropathy. The pudendal nerve is a mixed nerve having sensory, motor, and autonomic functions. As a result, inflammation or injury to the nerve can cause bladder, bowel, sexual and autonomic dysfunctions and perineal pain. Injuries typically affect pelvic and perineal sensations more severely than motor or autonomic nerve functions.[1] Pudendal neuralgia is generally a bilateral process characterized by perineal pain aggravated by sitting and affects >50% of patients with pudendal nerve entrapment.[2] The condition is frequently misdiagnosed initially and is often refractory [unyielding] to treatment, causing intense, chronic, debilitating pain. 

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Pudendal neuralgia is primarily a clinical diagnosis that is suggested by characteristic features, sometimes referred to as the "Nantes" criteria.[3][4] However, pudendal neuralgia is usually diagnosed only after many years of painful symptoms, with patients having undergone multiple evaluations, medication trials, procedures, interventions, and even surgeries. In addition to pain medicine specialists, end-organ specialists often treat patients, including gynecologists, colorectal surgeons, and urologists. The condition is significantly underdiagnosed and often inadequately or improperly treated. Consequently, a patient's quality of life is dramatically negatively impacted by resulting conditions, including depression and opioid addiction. In some cases, delays in diagnosis and proper treatment have led to confirmed patient suicides.

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As pudendal neuropathy is often a tunnel entrapment syndrome, treatment is analogous to carpal tunnel syndrome, including initial conservative nerve protection measures, physical therapy, pharmacologic therapy, pudendal nerve blocks, sacral neuromodulation, and surgical decompression of the pudendal nerves.[3][4] However, pudendal neuralgia and nerve entrapment are largely unknown and unstudied conditions [especially in the U.S]. Therefore, there is a general lack of quality research or studies demonstrating the optimal treatment strategy. The information presented here is based on the best peer-reviewed medical literature and consensus expert opinions.

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Decompressive Surgery

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Decompressive surgery is the most definitive treatment for persistent PN. The condition is often considered a "tunnel" syndrome, so decompressive surgery is frequently a curative option for patients. Furthermore, nerve entrapment is only definitively confirmed at the time of surgery. One randomized control study demonstrated the benefit of surgery over conservative care, recommending surgical decompression as the preferred treatment for PN.[60]  The overall success rate reported for decompressive surgery in appropriately selected patients with PN is 60% to 80%.[61]

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The most common site for pudendal nerve compression is in the interligamentary space between the sacrospinous and sacrotuberous ligaments. The second most common site is within Alcock's canal (ie, the pudendal canal). The falciform process may also compress the nerve. Congenital compression may be due to aberrant fascias, or the nerve may be squeezed between layers of the sacrotuberous ligament. Multiple anatomic variations of the pudendal nerve have been described.[32][62] Subsequently, the goal of decompressive surgery is the total release of the entire nerve trunk to allow complete mobility.[3]

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Indications for decompressive surgery are severe pain or symptoms unresponsive to other therapies, including conservative measures, medications, and image-guided [diagnostic] pudendal nerve blocks. A positive response to an anesthetic injection of the pudendal canal is highly suggestive of a good outcome from decompressive surgery [and should be required along with all five of the Nantes criteria]. [61][63] 

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During nerve healing after nerve decompression surgery, medications are often needed for several months to control pudendal pain and treat central sensitization. Treatment of other associated abdominal wall neuropathies also should be continued.

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Pudendal Neuralgia Alliance

contact@pudendalneuralgiaalliance.org

© 2024 by Made with Wix ™ by volunteer

Paid for by founder until 501c3 status granted by IRS

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