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Pudendal Neuropathy

as an Etiology of
Chronic Perineal Pain:
Diagnosis and
CharlesTreatment
Popeney, Van Ansell, Ken
Renney

Fort Bend Neurology


Foundation Surgical Hospital
Houston Orthopedic Sports Medicine
Associate
Study Objective
To illustrate the diagnosis of
pudendal neuropathy as an etiology
of chronic perineal pain. This study
analyzes a diagnostic protocol for
pudendal neuropathy as well as
clinical response to surgical
decompression.
Participants
 58 patients having had surgical
decompression
 Diagnosed with unilateral or bilateral
pudendal neuropathy
 Retrospective Study
Main Features for
Diagnosis
 Chronic, progressive burning pain in
the perineum (ano-rectal and/or
urogenital) that was worse with
sitting
 Included pain in testicles, penis, or
rectum in males
 Included pain in the labia, clitoris,
and rectum in females
Location of Pain
Males Females

Perineum Perineum
83.87% 75.00%
Testicles Labia
67.74% 37.50%
Penis Clitoris
29.03% 33.33%
Rectum Rectum
38.71% 70.83%
Additional Features
 Urinary hesitancy, frequency and
urgency (40%)
 Constipation (29%) including painful
bowel movements
 Sexual dysfunction (33%)
Prior Diagnosis
 Interstitial Cystitis (30%)
 Vulvadynia (50%)
 Endometriosis (13%)
 Prostatitis or epidymitis (63%)
 Piriformis Syndrome (20%)
 Levator Ani Syndrome (3%)
 Coccydynia (6%)
 Lumbosacral Radiculopathy (3%)
 Chronic Pelvic Pain Syndrome (20%)
Patient Profile
 Had seen multiple physicians
 Failed multiple pharmacologic
treatments
 Failed physiotherapy and perineal
hyperprotection
 Severely disabled by pain
 No evidence of organ disease
(negative work up for prostatitis,
epidymitis, negative scans of pelvic
and lumbosacral spine, normal
colorectal evaluation and
Disabling Symptoms
Average VAS Before Surgery: 6.06 Range
(2-10)
Question (before surgery): If you were to
spend the rest of your life with your
symptoms just the way they have been
during the last week, how would you feel
about that?
---- 86.21% of patients answered Terrible or
Unhappy

Question (before surgery): How much have


your symptoms kept you from doing the
kinds of things you would usually do over
the last month?
Diagnostic Criteria
 Burning pain in distribution of the
pudendal nerve that was aggravated
with sitting with or without voiding,
erectile, or rectal dysfunction without
evidence of organ disease
 These patients all had positive
diagnostic blocks that reduced their
pain or prolonged pudendal distal
motor latencies
Pudendal Nerve Blocks
 All patients, same physician
 First 2 blocks bilateral ischial spine
 3rd block Alcock’s canal
 Depomedrol 40 mg, 5cc of 1%
Lidocaine
 Anesthetic response assessed by VAS
before and shortly after block while
sitting on hard bench
Pudendal Nerve Distal
Motor Latency
 All patients, same physician
 Bilateral PNMLT and EMG
 Normal Latency < 4 ms
 Acute and chronic
denervation/reinnervation during
EMG
Indications for Surgery
 Diagnosis of Pudendal Neuropathy
per protocol
 Failed conservative treatment
 No lasting improvement for steroid
effect of pudendal block
Surgical Exploration and
Release
 Section Sacrotuberous
ligament
~ Explore Proximal Nerve
 Incise Alcock’s Canal
 Section Sacrospinous
ligament
 Transpose pudendal
nerve
Common Surgical
Findings
 Hypertrophic
ligaments
 Conjoined ligaments
 Adhesions
 Proximal branching
 Branch penetrating
SSL
 Thickened obturator
fascia
Post-op Surveys
 58 patients were independently
assessed in an uncontrolled
retrospective consecutive case series
by 1 year post-op surveys
 Degree of pain was assessed by pre
and post op VAS Score, % global
overall improvement, and improved
function and quality of life as
assessed by NIH-CPSI questions.
 Morbidity Questions

Post-op Questionnaire
When was your surgery?
 From month to month following surgery, has your pain been decreasing? If so, what is your overall
percent improvement?
 How often have you had pain or discomfort in any of the previously afflicted areas since surgery?
a. Never (score = 4)
b. Rarely (score = 10/3)
c. Sometimes (score = 8/3)
d. Often (score = 2)
e. Usually (score = 4/3)
f. Always (score = 2/3)
 Which number best describes your average pain or discomfort on the days you had it since surgery?
VAS 1-10
 How much have your symptoms kept you from doing the kinds of things you would usually do, since
surgery?
a. None (score = 4)
b. Only a little (score = 3)
c. Some (score = 2)
d. A lot (score = 1)
 How much do you think about your symptoms since surgery?
a. None (score = 4)
b. Only a little (score = 3)
c. Some (score = 2)
d. A lot (score = 1)
 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?
a. Delighted (score = 4)
b. Pleased (score = 3.5)
c. Mostly satisfied (score = 3)
d. Mixed (score = 2.5)
e. Mostly dissatisfied (score = 2)
f. Unhappy (score = 1.5)
g. Terrible (score = 1)
 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 areas of numbness related to the surgery?
Patient Demographics
Feature Study Group
(N=58)
Patient Characteristics
Sex
Female 26 (44.83)
Male 32 (55.17)
Age- years
Mean (Range) 45.71 (21-78)(stdev=11.843)
Time with symptoms before
surgery-months 47.38 (1-180)(stdev=47.553)
Mean (Range)
Motor Latency Distal Pudendal 3.26 (.90-9.80)(stdev=1.711,
Nerve- ms n=116)
* Values are number (percentage) unless
Mean (Range)
otherwise indicated
Defining Responders
 Reduction of VAS Score by 50% or
more or
 Greater than 50% Global overall
improvement or
 Increase by 50% in NIH-CPSI
function/quality questions
Results
Feature Study Group
(N=58)
Responders 35 (60.34)
Sex
Female 14 (40)
Male 21 (60)
Age- years
Mean (Range) 45.77 (21-
Time with symptoms before 78)(stdev=12.696)
surgery-months
Mean (Range)
Motor Latency Distal Pudendal 43.49 (1-
Nerve- ms 180)(stdev=48.598)
Mean (Range)
* Values are number (percentage) unless
Results cont.
Feature Study Group
(N=58)
Nonresponders 23 (39.66)
Sex
Female 12 (52.17)
Male 11 (47.83)
Age- years
Mean (Range) 45.61 (25-
Time with symptoms before 62)(stdev=10.689)
surgery-months
Mean (Range)
Motor Latency Distal Pudendal 53.30 (8-
Nerve- ms 156)(stdev=46.345)
Mean (Range)
* Values are number (percentage) unless
Morbidity
 Urinary incontinence 1 (1.2%)
 Numbness in small patch of the
pudendal nerve (vaginal, rectal,
perineum areas) 7 (12%)
 S.I. joint dysfunction 5 (8.6%)
Responder/Nonresponder
Analysis
 Age
 Gender
 Duration of symptoms
 Degree of prolonged distal latency

Conclusion: Did not predict failure or


success of surgical outcome
The Future
 Further neurophysiology
 BCR
 QST
 Further intraoperative monitoring
- reducing morbidity
- ? improved perisurgical latencies
 Continued look at non-responders
 Continued care for non-responders
- Botox
- Sacral Modulation