Download Pudendal Neuralgia

Pudendal Neuralgia
Anouk Speek
VCU DPT Class of 2017
27 July 2016
What is Pudendal Neuralgia?
 Mechanical or Inflammatory irritation of the pudendal nerve
 2/3 of sufferers are women
 1/100,000
 Often misdiagnosed and inappropriately treated
Anatomy

Lumbo-Sacral Plexus (L4-S4)>Pudendal nerve(S2-S4)>

Inferior rectal nerve (sensory)
 Anal canal, peri-anal skin, rectum, external anal sphincter

Perineal nerve (sensory)
 Perineum, Vagina, Urethra, male scrotum, Labia, transverse perineal muscle, urethral sphincter

Dorsal nerve of the clitoris/penis (sensory)
 Skin of the clitoris/penis, bulbocavernosus muscle, ischiocavernosus muscle

Motor portion
 External anal sphincter, sphincter muscles of bladder, muscles of pelvic floor

Sensory (80%) and Motor fibers (20%)

Only nerve with both autonomic and somatic fibers:

^ Heart Rate

^ Blood Pressure

^ Perspiration

Decreased motility of colon

Decreased blood flow
Symptom location
 Females: vulva, clitoris, vagina,
perineum, rectum
 Males: glans penis, scrotum
(excluding testicles), perineum,
rectum
 A – pudendal nerve
 B – inferior cluneal nerve
 C – Obturator nerve
 D – ilioinguinal and
genitofemoral nerves
Pudendal Nerve- Female
Pudendal Nerve - Male
 The pudendal nerve comes from
the sacral plexus (S2-S4) and
enters the gluteal region through
the lower part of the greater
sciatic foramen. It runs through the
pelvis around ischial spine and
between the sacrospinous and
sacrotuberous ligaments through
Alcock’s Canal. It splits up into the
rectal/anal, perineal and clitorial/
penis branches.
Pelvic Floor Anatomy
 Three layers:
1. Superficial perineal Layer (Pudendal Nerve Innervation)
1. Bulbocavernsus, Ischocavernosus, Superficial transverse perineal, External
Anal Sphincter
2. Deep Urogenital Diaphragm layer (Pudendal Nerve Innervation)
1. Compressor Urethra, Uterovaginal Sphincter, Deep transverse Perineal
3. Pelvic Diaphragm (Sacral Roots S3-S5)
1. Levator Ani (Pubococcygeus, Iliococcygeus),
Coccygeus/Ischiococcygeus, Piriformis, Obturator Internus
Possible causes

Childbirth

Entrapment at Alcock’s canal/“Cyclist’s Syndrome”

Entrapment between sacrospinous and sacrotuberous ligaments

Trauma (Fall, pelvic fx, etc.)

Pelvic sling operations

Stretching (HS)

Prolonged sitting

Endometriosis

Anatomy/genetic predisposition

Compression from tumour

Prolonged straining/passing stool

Inflammatory/Auto-immune

Frequent infections

Asymmetric skeleton/muscle imbalance

** entrapment is most likely caused by Levator Ani or Obturator internus spasm, ligament pressure (sacrospinous or
sacrotuberous), scar tissue from surgery or trauma
Top Causes
Women
Men
Pelvic Surgery *especially for
prolapse/incontinence
Pelvic Trauma
Pelvic trauma/falls
Childbirth
Diagnosis – Clinical!
 Image-guided Pudendal nerve block (also a treatment)
 Pudendal nerve Motor latency test (replaced by nerve block)
 MRI/CT scan
 Nantes’ Criteria (Pudendal n. entrapment)
 Inclusion criteria: Pain situated in the anatomical territory of the pudendal nerve, worsened by
sitting, the patient is not woken at night by the pain, no objective sensory loss is detected on
clinical examination, and positive pudendal nerve block
 Exclusion criteria: purely coccygeal, gluteal, or hypogastric pain, exclusively paroxysmal pain,
exclusive pruritus, presence of imaging abnormalities able to explain the symptoms
 Red flags: waking up at night, excessively neuropathic nature of the pain, specifically
pinpointed pain
 Symptoms/history
 Internal exam; Levator Ani, Obturator Internus, sensitive Bladder, sacrospinous ligament
 Tinell’s sign
Differential Diagnoses

Low back Pain

SI joint dysfunction

Sacral radiculopathies

Endometriosis

Piriformis dysfunction

Hip pain/labrum/joint

Tumours

Pelvic Floor Dysfunction

Disease of the skin/spine

Gynecological, urological, proctological conditions, Prostatodynia

Nonbacterial Prostatitis

Vestibulitis

Idiopathic vulvodynia

Idiopathic proctalgia

Idiopathic penile pain syndrome

Interstitial cystitis

Other nerves; lateral femoral cutaneous, posterior femoral cutaneous, genitofemoral, Obturator nerve
Signs/Symptoms

Pelvic pain relieved with standing and/or sitting on a toilet**

Hyperesthesia; discomfort with tight clothing**

Bladder/bowel sx (hesitancy, frequency, urgency, retention, constipation, pain)

Dyspareunia

Low abdomen pain

Erectile Dysfunction

Pain with orgasm

Genital pain

Anal pain

Relief of sx with Pudendal nerve block

Itching, burning, tingling, cold feeling, shooting pain, stabbing, pin pricking, numbness, twisting, pulling

Unilateral or bilateral (even if entrapment is unilateral)

Posterior thigh pain

Groin pain

Allodynia; pain with nonpainful stimulus
PT Treatment/Intervention
 Patient Education
 Strength, mobility, endurance, manual therapies to Pelvic floor, abdominal, gluteal, hip rotator
muscles
 Pudendal nerve mobilisation
 Connective tissue mobilization (external and internal)
 Myofascial release (external and internal)
 Trigger Point Release
 Normalise structure and mechanics i.e. pelvic obliquities, hip mechanics, neuromuscular control of
core
 Posture correction
 Relaxation techniques
 What to avoid? Depends on the patient…PFM contraction, positioning, etc.
 Precautions
 Hip flexion past 90 degrees
 Hip flexion past 90 degrees and ER
 End range ER/IR
Intervention progression
 PT, PT, PT!!
PT 2-3/week, HEP, Relaxation techniques for 6 months
Anti-depressants/Anti-Convulsants/Muscle Relaxers
Trigger point injections/Pudendal nerve block/Steroid injections/Botox injections
Radiofrequency ablation/Cryoablation**
IV infusion therapy/Spinal Cord Stimulation (SCS)/Intrathecal pumps
Surgery
1.Trans-Ischio-rectal
2.Trans-gluteal
3.Trans-perineal
4.Laprascopic
Complications from surgery: pain at incision site, scar tissue, SI jt dysfunction, gluteal tearing,
sciatic nerve tension
Back to PT?
Prognosis
 Depends on the patient!
 Psychosocial component
 International Pudendal Neuropathy Association (Tipna.org)
Differential Diagnosis of Pelvic Floor
Dysfunction in Orthopaedics
 Pain/shooting/stabbing straight through hip Anterior to posterior
 Bladder/bowel dysfunction
 Low back pain with L/S and LE ruled out
 Pelvic Obliquities
 Low abdominal pain
 Breathing dysfunction
 Check TrA activation!
 OLS for load transfer
 ASLR (bulging)
 Ant compression ASIS – TrA/ lower IO
 Post compression PSIS – Multifidus
 Ant compression pubic symphysis – anterior PFM/low TrA/IO
 Post compression IT – posterior PFM
References
 Pudendal Neuralgia. Michael Hibner MD, PhD Nita Desai MD, Loretta J. Robertson PT, and May
Nour MD, PhD. Journal of Minimally Invasive Gynecology, The, 2010-03-01, Volume 17, Issue 2,
Pages 148-153, Copyright © 2010 AAGL
 Dr. Amanda Miller, Gender Health Lecture, VCU 2/29/2016
 Pudendal Neuralgia due to Pudendal Nerve Entrapment: Warning signs Observed in Two Cases
and review of the literature. Ploteau S, Cardaillac C, Perrouin-Verbe MA, Riant T Labat JJ. Pain
Physician, 2016 Mar; 19(3):E449-54
 Percutaneous CT-guided cryablation for the treatment of refractory pudendal neuralgia.Prologo
JD, Lin RC, Williams R, Corn D. Skeletal Radiol. 2015 May;44(5):709-14. doi: 10.1007/s00256-0142075-3. Epub 2014 Dec 17.
 http://www.beyondbasicsphysicaltherapy.com/pudendal-nerve-neuralgia
 https://www.urmc.rochester.edu/medialibraries/urmcmedia/imaging/patients/documents/pude
ndal_neuralgia_brochure.pdf
 http://ainsworthinstitute.com/conditions/pudendal-neuralgia/
 http://www.pudendalhope.info/node/8#5
 https://www.glowm.com/section_view/heading/Pudendal%20Neuralgia/item/691
 https://www.studyblue.com/notes/note/n/anatomy-gluteus-and-anal-regions/deck/1890005