Chronic Pelvic Pain: Neurogenic or Non-Neurogenic? Warm Detection Threshold Testing Supports a Diagnosis of Pudendal Neuropathy.

BACKGROUND: Chronic pelvic pain (CPP) in men is rarely considered to have a neurogenic (neuropathic) basis. Separation of neurogenic from non-neurogenic pain is possible using clinical examination and neurophysiologic tests. A definite diagnosis of neuropathic pain can be made. OBJECTIVES: We aim to demonstrate that definite pudendal neuropathic abnormalities can be supported by a quantitative sensory test (QST) called the warm temperature threshold detection (WDT) test in men with CPP. STUDY DESIGN: This is a retrospective review of 25 consecutive, unrecruited men evaluated in a private clinical practice beginning on January 1, 2010. The techniques of examination and neurophysiological testing have been standard since 2003. SETTING: A private practice that is a referral center because of its focus on CPP of a neuropathic basis. METHODS: Pinprick sensation was evaluated at 6 sites in the pudendal nerve territory (3 branches on each side). A WDT was performed at each nerve branch using a Physitemp NTE-2C Thermoprobe and Controller. This used a stepping algorithm from a neutral baseline of 31.5°C. Quantitative and subjective "qualitative responses" were recorded. Our preferred symptom score to evaluate pain level at consultation is the National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI). The results become the benchmark for comparison of responses following future treatments (not discussed). When possible, microscopy was used to evaluate prostate secretions for inflammatory prostatitis except in 2 men with CPP who had undergone previous radical prostatectomy for cancer. Observations were made of the skin in the pudendal territory. Our specific evaluation for neuropathy also sought evidence of multiple additional neuropathic pelvic pain generators. RESULTS: The WDT was abnormal in all men (88% quantitative), and pinprick sensation was abnormal in 92% of the men. The combination of tests provided a diagnosis of pudendal neuropathy in all patients, resulting in an accurate and timely explanation of the neurogenic basis of their CPP symptoms. The NIH-CPSI scores ranged from 10 to 35 (median 25). Four of 15 men had inflammatory prostatitis in addition to pudendal neuropathy. LIMITATIONS: There is selection bias because the men were either self-referred, suspecting their diagnosis from internet searches, or were referred by physicians who were aware of the focus of this clinical practice. The warm temperature testing used established normal values for the men. The NIH-CPSI does not evaluate sexual or bowel symptoms. Sensitivity or specificity values for the tests could not be obtained. CONCLUSIONS: A possible neuropathic basis for CPP in men can be suspected from symptoms and history of activities. A probable diagnosis of neuropathy can be determined using a pinprick sensory evaluation in the pudendal territory. A definite diagnosis of pudendal neuropathy can be made using WDT. The combination of these 2 examinations demonstrated pudendal neuropathy in 100% of this cohort.The institutional review board deemed this study met criteria for exemption. KEY WORDS: Chronic pelvic pain, pudendal neuropathy, quantitative sensory testing, warm temperature detection threshold test, neuropathic pelvic pain, definite diagnosis of neuropathy, chronic prostatitis.

Measuring the Quality of Pudendal Nerve Perineural Injections.

BACKGROUND: Pudendal neuropathy is a tunnel syndrome characterized by pelvic pain and may include bowel, bladder, or sexual dysfunction or a combination of these. One treatment method, pudendal nerve perineural injections (PNPIs), uses infiltration of bupivacaine and corticosteroid around the nerve to provide symptom relief. Bupivacaine also anesthetizes the skin in the receptive field of the nerve that is injected. Bupivacaine offers rapid pain relief for several hours while corticosteroid provides delayed pain control often lasting 3 to 5 weeks. Not all pudendal nerve blocks may provide complete pain relief but long-term pain control from the steroid appears to be associated with immediate response to bupivacaine. We offer a method of evaluating the quality of a pudendal block on the day it is performed using pinprick sensation evaluation. OBJECTIVE: To demonstrate that pinprick sensory changes provide a simple and rapid method of measuring response to local anesthetic and pain reduction provided by a PNPI on the day it is performed. This response defines the quality of each PNPI. STUDY DESIGN: This is a case series based on retrospective review of a private practice database that is maintained by HealthEast hospitals in Minnesota. Database information includes standard physical examination, recording techniques, and treatment processes that had been in place for several years. SETTING: Private practice in United States. METHODS: Patients with a diagnosis of pudendal neuropathy are treated with PNPIs. Two hours after each block, 2 endpoints are measured: response to a sensory pinprick examination of the pudendal territory and difference in patient-reported pain level before and after nerve block. Fifty-three men from a private practice treating only pelvic pain received the treatment in 2005. Reported pain level was not recorded for 2 patients. RESULTS: Bupivacaine in perineural injections produces varying degrees of analgesia or hypalgesia to pinprick. Normal pinprick response suggests pudendal nerves were not penetrated by bupivacaine. Patient responses varied from complete, i.e. all 6 branches anesthetized to none. Most men had 2 - 5 nerve branches anesthetized. One man had a single nerve branch that responded to bupivacaine. Three men failed to respond to local anesthetic.Changes in pre-PNPI to post-PNPI pain scores were significantly decreased (n = 51, P-value < 0.0001), indicating that bupivacaine in the PNPI reduced pain. Forty-one patients (80.4%) indicated less pain after the procedure and only 2 patients (4.0%) indicated more pain. The number of nerve branches successfully anesthetized was also significantly correlated with change in score. On average, an additional successful nerve branch anesthetized corresponded to a drop of about 0.66 in the change score (n = 51, P - value = 0.0005). CONCLUSION: PNPIs relieve pain. Anesthesia affected all 6 pudendal nerve branches in only 13.2% of patients. Complete pain relief occurred in 39.2%. This argues against use of perineural pudendal blockade as a diagnostic test. Pain relief after PNPI is associated with number of nerve branches that are anesthetized. At 2 hours after a PNPI its quality (the number of the 6 nerve branches with reduced response to pinprick from the perineural local anesthetic) is associated with subjective reduction of pain. KEY WORDS: Pudendal neuralgia, chronic perineal pain, pudendal nerve block, sensory examination, neurologic examination, pain management, chronic pelvic pain syndrome.

Therapeutic pudendal nerve blocks using corticosteroids cure pelvic pain after failure of sacral neuromodulation.

A patient with bladder frequency and urgency associated with pelvic pain had no control of symptoms by previous bladder distention, hysterectomy, or sacral nerve root stimulator. A clinical and neurophysiological diagnosis of pudendal neuropathy was made. Treatment with a nerve protection program and pudendal nerve perineural injections of local anesthetics and corticosteroids has provided total symptomatic relief that is durable.

Anatomical basis of chronic pelvic pain syndrome: the ischial spine and pudendal nerve entrapment.

Chronic pelvic pain syndrome is a conundrum that may be explained partly by pudendal nerve entrapment (PNE), which causes neuropathic pain. In men with PNE, aberrant development and subsequent malpositioning of the ischial spine appear to be associated with athletic activities during their youth. The changes occur during the period of development and ossification of the spinous process of the ischium.