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Current Sexual Health Reports

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01-12-2018 | Medical Comorbidities (A Goldstein, M Miner and S Parish, Section Editors)

Pudendal Neuralgia: Making Sense of a Complex Condition

Author: Richard P. Marvel

Published in: Current Sexual Health Reports | Issue 4/2018

Abstract

Purpose of Review

Clinicians have become increasingly aware of pudendal neuralgia as a cause of persistent genital pain. The purpose of this review is to summarize the current knowledge regarding the presentation, etiology, evaluation, and management of this condition.

Recent Findings

Pudendal neuralgia can be reliably diagnosed and successfully managed. There are many available treatments that can lead to marked improvement and normalization of quality of life in the majority of patients. Most treatments can be instituted and managed by primary care physicians with a small percentage requiring the expertise of specialists for advanced treatment approaches, such as neuromodulation or surgical decompression.

Summary

Pudendal neuralgia is a persistent neuropathic pain condition with alteration of the pudendal nerve structure and/or function. It can present with mild, moderate, or severe pain and be disabling. At times, it is a component of overlapping persistent pain conditions. Most patients can be successfully managed without surgical intervention.

•• Maixner W, Fillingim RB, Williams DA, Smith SB, Slade GD. Overlapping chronic pain conditions: implications for diagnosis and classification. J Pain [Internet] Elsevier Inc. 2016;17:T93–107. https://doi.org/10.1016/j.jpain.2016.06.002. This article by some of the most respected authors in pain research describes the new paradigm of overlapping conditins. It also stresses the need not to eliminate research subjects if they have a multitude of conditions.CrossRef

Labat JJ, Riant T, Robert R, Amarenco G, Lefaucheur JP, Rigaud J. Diagnostic criteria for pudendal neuralgia by pudendal nerve entrapment (Nantes criteria). Neurourol Urodyn. 2008;27:306–10.CrossRef

Harlow BL, Stewart EG. A population-based assessment of chronic unexplained vulvar pain: have we underestimated the prevalence of vulvodynia? J Am Med Womens Assoc [Internet]. 2003;58:82–8 Available from: http://www.ncbi.nlm.nih.gov/pubmed/12744420 .

Loukas M, Louis RG, Hallner B, Gupta AA, White D. Anatomical and surgical considerations of the sacrotuberous ligament and its relevance in pudendal nerve entrapment syndrome. Surg Radiol Anat. 2006;28:163–9.CrossRef

Maldonado PA, Chin K, Garcia AA, Corton MM. Anatomic variations of pudendal nerve within pelvis and pudendal canal: clinical applications. Am J Obstet Gynecol. 2015;213:727e1–6.CrossRef

Klind perineal nerve block an anatomic and clinical study in the female Ob gyn 1953; feb 1(20 1–46.pdf).

Moszkowicz D, Alsaid B, Bessede T, Zaitouna M, Penna C, Benoit G, et al. Neural supply to the clitoris: immunohistochemical study with three-dimensional reconstruction of cavernous nerve, spongious nerve, and dorsal clitoris nerve in human fetus. J Sex Med. 2011;8:1112–22.CrossRef

Peltier J. Anatomical basis of transgluteal approach for pudendal neuralgia and operative technique. Surg Radiol Anat. 2013;35:609–14.CrossRef

Vancaillie T, Eggermont J, Armstrong G, Jarvis S, Liu J, Beg N. Response to pudendal nerve block in women with pudendal neuralgia. Pain Med. 2012;13:596–603.CrossRef

10.

Jilliffee SE, White WA. Affections of the peripheral nerves: sensory and motor. Dis Nerv Syst A Text-b Neurol Psychiatry. Philadelphia and New York: Lea and Febiger; 1915. p. 271–2.

11.

Kennedy J. Neurologic injuries in cycling and bike riding. Phys Med Rehabil Clin N Am. 2009;20:241–8.CrossRef

12.

Sommer F, König D, Graf C, Schwarzer U, Bertram C, Klotz T, et al. Impotence and genital numbness in cyclists. Int J Sports Med. 2001;22:410–3.CrossRef

13.

Snooks SJ, Swash M, Setchell M, Henry MM. Injury to innervation of pelvic floor sphincter musculature in childbirth. Lancet. 1984;324:546–50.CrossRef

14.

Sultan AH, Kamm MA, Hudson CN. Pudendal nerve damage during labour: prospective study before and after childbirth. BJOG Int J Obstet Gynaecol. 1994;101:22–8.CrossRef

15.

Tetzschner T, Sorensen M, Jonsson L, Lose G, Christiansen J. Delivery and pudendal nerve function. Acta Obstet Gynecol Scand. 1997;76:324–31.CrossRef

16.

Snooks SJ, Swash M, Mathers SE, Henry MM. Effect of vaginal delivery on the pelvic floor: a 5-year follow-up. Br J Surg. 1990;77:1358–60.CrossRef

17.

Brown R, Pedowitz R, Rydevik B, Woo S, Hargens A, Massie J, et al. Effects of acute graded strain on efferent conduction properties in the rabbit tibial nerve. Clin Orthop Relat Res. 1993;296:288–94.

18.

Lien KC, Morgan DM, Delancey JOL, Ashton-Miller JA. Pudendal nerve stretch during vaginal birth: a 3D computer simulation. Am J Obstet Gynecol. 2005;192:1669–76.CrossRef

19.

Oaklander AL, Rissmiller JG. Postherpetic neuralgia after shingles: an under-recognized cause of chronic vulvar pain. Obstet Gynecol. 2002;99:625–8.PubMed

20.

Johnson RW, Rice ASC. Postherpetic neuralgia. N Engl J Med. 2014;371:1526–33.CrossRef

21.

Alevizon SJ, Finan MA. Sacrospinous colpopexy: management of postoperative pudendal nerve entrapment. Obstet Gynecol. 1996;88:713–5.CrossRef

22.

Masata J, Hubka P, Martan A. Pudendal neuralgia following transobturator inside-out tape procedure (TVT-O) - case report and anatomical study. Int Urogynecol J. 2012;23:505–7.CrossRef

23.

Habib A, Haldane CE, Ekhtiari S, de SAD, Simunovic N, Belzile EL, et al. Pudendal nerve injury is a relatively common but transient complication of hip arthroscopy. Knee Surgery, Sport Traumatol Arthrosc. 2018;26:969–75.CrossRef

24.

Amarenco G, Ismael SS, Bayle B, Denys P, Kerdraon J. Electrophysiological analysis of pudendal neuropathy following traction. Muscle Nerve. 2001;24:116–9.CrossRef

25.

Vancaillie T, Eggermont J, Armstrong G, Jarvis S, Liu J, Beg N, et al. Pudendal nerve branch injury during radical perineal prostatectomy. Pain Physican [Internet] Elsevier Inc. 2011;24:943–52 Available from: http://www.ncbi.nlm.nih.gov/pubmed/19461829.

26.

Warner MA, Warner DO, Harper CM, Schroeder DR, Maxson PM. Lower extremity neuropathies associated with lithotomy positions. Anesthesiology. 2000;93:938–42.CrossRef

27.

Possover M, Forman A. Pelvic neuralgias by neuro-vascular entrapment: anatomical findings in a series of 97 consecutive patients treated by laparoscopic nerve decompression. Pain Physician [Internet]. 2015;18:E1139–43 Available from: http://www.scopus.com/inward/record.url?eid=2-s2.0-84947925316&partnerID=tZOtx3y1.

28.

Pereira A, Pe’rez-Medina T, Rodrıuez-Tapia A, Rutherford S, Millan I, Iglesias E, et al. Chronic perineal pain analyses of prognostic factors in pudendal neuralgia. Clin J Pain 2014;30:577–82.

29.

Rovenstine EA, Wertheim HM. Therapeutic nerve block. JAMA J Am Med Assoc. 1941;117:1599–603.CrossRef

30.

31.

Wadhwa V, Scott KM, Rozen S, Starr AJ, Chhabra A. CT-guided perineural injections for chronic pelvic pain. RadioGraphics [Internet]. Radiological Society of North America. 2016;36:1408–25 [cited 2018 Mar 1] Available from: http://pubs.rsna.org/doi/10.1148/rg.2016150263.

32.

Vancaillie T, Eggermont J, Armstrong G, Jarvis S, Liu J, Beg N. Response to pudendal nerve block in women with pudendal neuralgia. Pain Med. 2012;13:596–603.CrossRef

33.

Antolak SJ, Antolak C, Lendway L. Measuring the quality of pudendal nerve perineural injections. Pain Physician [Internet]. 2016;19:299–306 Available from: https://www.scopus.com/inward/record.uri?eid=2-s2.0-84970024091&partnerID=40&md5=8dcb0c126dda50a590fdb456570916e1.

34.

Bellingham GA, Bhatia A, Chan C, Peng PW. Randomized controlled trial comparing pudendal nerve block under ultrasound and fluoroscopic guidance. Reg Anesth Pain Med [Internet]. 2012;37:262–6 Available from: http://content.wkhealth.com/linkback/openurl?sid=WKPTLP:landingpage&an=00115550-201205000-00005.CrossRef

35.

Benson JT, Griffis K. Pudendal neuralgia, a severe pain syndrome. Am J Obstet Gynecol. 2005;192:1663–8.CrossRef

36.

•• Carey ET, As-Sanie S. New developments in the pharmacotherapy of neuropathic chronic pelvic pain. Futur Sci OA [Internet]. 2016;2:FSO148 Available from: http://www.ncbi.nlm.nih.gov/pubmed/28116131%5Cn, http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=PMC5242194. This article is an excellent review of the pharmacologic management of women with neuropathic chronic pelvic pain conditions.

37.

Dworkin RH, Corbin AE, Young JP, Sharma U, LaMoreaux L, Bockbrader H, et al. Pregabalin for the treatment of postherpetic neuralgia: a randomized, placebo-controlled trial. Neurology. 2003;60:1274–83.CrossRef

38.

Zeidan F, Emerson NM, Farris SR, Ray JN, Jung Y, McHaffie JG, et al. Mindfulness meditation-based pain relief employs different neural mechanisms than placebo and sham mindfulness meditation-induced analgesia. J Neurosci [Internet]. 2015;35:15307–25. Available from: http://www.jneurosci.org/cgi/doi/10.1523/JNEUROSCI.2542-15.2015.CrossRef

39.

Shpaner M, Kelly C, Lieberman G, Perelman H, Davis M, Keefe FJ, et al. Unlearning chronic pain: A randomized controlled trial to investigate changes in intrinsic brain connectivity following Cognitive Behavioral Therapy. NeuroImage Clin. 2014;5:365–76.CrossRef

40.

Castelnuovo G, Giusti EM, Manzoni GM, Saviola D, Gatti A, Gabrielli S, et al. Psychological treatments and psychotherapies in the neurorehabilitation of pain: Evidences and recommendations from the italian consensus conference on pain in neurorehabilitation. Front. Psychol. 2016.

41.

FitzGerald MP, Anderson RU, Potts J, Payne CK, Peters KM, Clemens JQ, et al. Randomized multicenter feasibility trial of myofascial physical therapy for the treatment of urological chronic pelvic pain syndromes. J Urol [Internet] American Urological Association. 2009;182:570–80. https://doi.org/10.1016/j.juro.2009.04.022.CrossRef

42.

43.

Kim SH, Song SG, Paek OJ, Lee HJ, Park DH, Lee JK. Nerve-stimulator-guided pudendal nerve block by pararectal approach. Color Dis. 2012;14:611–5.CrossRef

44.

McDonald JS, Spigos DG. Computed tomography-guided pudendal block for treatment of pelvic pain due to pudendal neuropathy. Obstet Gynecol. 2000;95:306–9.

45.

Fritz J, Chhabra A, Wang KC, Carrino JA. Magnetic resonance neurography-guided nerve blocks for the diagnosis and treatment of chronic pelvic pain syndrome. Neuroimaging Clin N Am. 2014;24:211–34.CrossRef

46.

Rofaeel A, Peng P, Louis I, Chan V. Feasibility of real-time ultrasound for pudendal nerve block in patients with chronic perineal pain. Reg Anesth Pain Med. 2008;33:139–45.CrossRef

47.

Zacchino M, Allegri M, Canepari M, Minella CE, Bettinelli S, Draghi F, et al. Feasibility of pudendal nerve anesthetic block using fusion imaging technique in chronic pelvic pain. Eur J Pain Suppl. 2010;4:329–33.CrossRef

48.

Robert R, Prat-Pradal D, Labat JJ, Bensignor M, Raoul S, Rebai R, et al. Anatomic basis of chronic perineal pain: role of the pudendal nerve. Surg Radiol Anat. 1998;20:93–8.CrossRef

49.

Vlassakov KV, Narang S, Kissin I. Local anesthetic blockade of peripheral nerves for treatment of neuralgias: systematic analysis. Anesth Analg. 2011;112:1487–93.CrossRef

50.

Mamlouk MD, Van Sonnenberg E, Dehkharghani S. CT-guided nerve block for pudendal neuralgia: diagnostic and therapeutic implications. Am J Roentgenol. 2014;203:196–200.CrossRef

51.

Mackinnon SE, Hudson AR, Gentili F, Kline DG, Hunter D. Peripheral nerve injection injury with steroid agents. Plast Reconstr Surg. 1982;69:482–9.CrossRef

52.

Labat JJ, Riant T, Lassaux A, Rioult B, Rabischong B, Khalfallah M, et al. Adding corticosteroids to the pudendal nerve block for pudendal neuralgia: a randomised, double-blind, controlled trial. BJOG Int J Obstet Gynaecol. 2017;124:251–60.CrossRef

53.

Rhame EE, Levey KA, Gharibo CG. Successful treatment of refractory pudendal neuralgia with pulsed radiofrequency. Pain Physician [Internet]. 2009;12:633–8 Available from: http://www.ncbi.nlm.nih.gov/pubmed/19461829.

54.

Masala S, Calabria E, Cuzzolino A, Raguso M, Morini M, Simonetti G. CT-guided percutaneous pulse-dose radiofrequency for pudendal neuralgia. Cardiovasc Intervent Radiol. 2014;37:476–81.CrossRef

55.

Vanneste T, Van Lantschoot A, Van Boxem K, Van Zundert J. Pulsed radiofrequency in chronic pain. Curr Opin Anaesthesiol. 2017;30:577–82.CrossRef

56.

Aló KM, McKay E. Selective nerve root stimulation (SNRS) for the treatment of intractable pelvic pain and motor dysfunction: a case report. Neuromodulation. 2001;4:19–23.CrossRef

57.

Chai TC, Zhang CO, Warren JW, Keay S. Percutaneous sacral third nerve root neurostimulation improves symptoms and normalizes urinary HB-EGF levels and antiproliferative activity in patients with interstitial cystitis. Urology. 2000;55:643–6.CrossRef

58.

Maher CF, Carey MP, Dwyer PL, Schluter PL. Percutaneous sacral nerve root neuromodulation for intractable interstitial cystitis. J Urol. 2001;165:884–6.CrossRef

59.

Aboseif Sherif sacral neuromodulation as effective treatment for refractory pelvic floor dysfunction.pdf.

60.

Sherar MD, Gertner MR, Yue CKK, O’Malley ME, Toi A, Gladman AS, et al. Sacral nerve stimulation in patients with chronic intractable pelvic pain. J Urol. 2001;166:1742–5.CrossRef

61.

Spinelli M, Malaguti S, Giardiello G, Lazzeri M, Tarantola J, Van Den Hombergh U. A new minimally invasive procedure for pudendal nerve stimulation to treat neurogenic bladder: description of the method and preliminary data. Neurourol Urodyn. 2005;24:305–9.CrossRef

62.

Peters KM, Feber KM, Bennett RC. A prospective, single-blind, randomized crossover trial of sacral vs pudendal nerve stimulation for interstitial cystitis. BJU Int. 2007;100:835–9.CrossRef

63.

Peters KM. Pudendal neuromodulation for sexual dysfunction. J Sex Med. 2013;10:908–11.CrossRef

64.

Peters KM, Killinger KA, Jaeger C, Chen C. Pilot study exploring chronic pudendal neuromodulation as a treatment option for pain associated with pudendal neuralgia. Low Urin Tract Symptoms. 2015;7:138–42.PubMed

65.

Heinze K, Hoermann R, Fritsch H, Dermietzel R, van Ophoven A. Comparative pilot study of implantation techniques for pudendal neuromodulation: technical and clinical outcome in first 20 patients with chronic pelvic pain. World J Urol. 2014;33:289–94.CrossRef

66.

Possover M. A novel implantation technique for pudendal nerve stimulation for treatment of overactive bladder and urgency incontinence. J Minim Invasive Gynecol [Internet] Elsevier Ltd. 2014;21:888–92. https://doi.org/10.1016/j.jmig.2014.03.026.CrossRef

67.

Marvel RP. Outcomes of pudendal neuromodulation in patients failing multiple conservative treatments for pudendal neuralgia. Neuromodulation. 2017;20:e700–1.

68.

Deer TR, Mekhail N, Provenzano D, Pope J, Krames E, Leong M, et al. The appropriate use of neurostimulation of the spinal cord and peripheral nervous system for the treatment of chronic pain and ischemic diseases: the neuromodulation appropriateness consensus committee. Neuromodulation. 2014;17:515–50.CrossRef

69.

Beco J, Climov D, Bex M. Pudendal nerve decompression in perineology: a case series. BMC Surg. 2004;4:1–17.CrossRef

70.

Shafik A, El-Sherif M, Youssef A, Olfat ES. Surgical anatomy of the pudendal nerve and its clinical implications. Clin Anat [Internet]. 1995;8:110–5 Available from: http://www.ncbi.nlm.nih.gov/pubmed/7712320.CrossRef

71.

Bautrant E, de Bisschop E, Vaini-Elies V, Massonnat J, Aleman I, Buntinx J, et al. Modern algorithm for treating pudendal neuralgia: 212 cases and 104 decompressions. J Gynecol Obstet Biol Reprod. 2003;32:705–12.

72.

Possover M. Laparoscopic management of endopelvic etiologies of pudendal pain in 134 consecutive patients. J Urol [Internet] American Urological Association. 2009;181:1732–6. https://doi.org/10.1016/j.juro.2008.11.096.CrossRef

73.

Dellon AL, Coady D, Harris D. Pelvic pain of pudendal nerve origin: surgical outcomes and learning curve lessons. J Reconstr Microsurg. 2015;31:283–90.CrossRef

74.

Wan EL, Dellon AL. Injury to the perineal branch of the pudendal nerve in men: outcomes from surgical resection of the perineal branches. Microsurgery. 2018;38:172–6.CrossRef

75.

Charlotte W, Sebastian D, Viviane T, Luc B. Selection criteria for surgical treatment of pudendal neuralgia. Neurourol Urodyn. 2017;36:663–6.

Title: Pudendal Neuralgia: Making Sense of a Complex Condition
Author: Richard P. Marvel
Publication date: 01-12-2018
Publisher: Springer US
Published in: Current Sexual Health Reports / Issue 4/2018
Print ISSN: 1548-3584
Electronic ISSN: 1548-3592
DOI: https://doi.org/10.1007/s11930-018-0177-y

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Pudendal Neuralgia: Making Sense of a Complex Condition

Abstract

Purpose of Review

Recent Findings

Summary

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Purpose of Review

Recent Findings

Summary

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