Diagnosis and treatment of pudendal and inferior cluneal nerve entrapment syndrome: a narrative review.

AIM: Pudendal and inferior cluneal nerve entrapment can cause a neuropathic pain syndrome in the sensitive areas innervated by these nerves. Diagnosis is challenging and patients often suffer several years before diagnosis is made. The purpose of the review was to inform healthcare workers about this disease and to provide a basis of anatomy and physiopathology, to inform about diagnostic tools and invasive or non-invasive treatment modalities and outcome. METHODS: A description of pudendal and inferior cluneal nerve anatomy is given. Physiopathology for entrapment is explained. Diagnostic criteria are described, and all non-invasive and invasive treatment options are discussed. RESULTS: The Nantes criteria offer a solid basis for diagnosing this rare condition. Treatment should be offered in a pluri-disciplinary setting and consists of avoidance of painful stimuli, physiotherapy, psychotherapy, pharmacological treatment led by tricyclic antidepressants and anticonvulsants. Nerve blocks are efficient at short term and serve mainly as a diagnostic tool. Pulsed radiofrequency (PRF) is described as a successful treatment option for pudendal neuralgia in patients non-responding to non-invasive treatment. If all other treatments fail, surgery can be offered. Different surgical procedures exist but only the open transgluteal approach has proven its efficacy compared to medical treatment. The minimal-invasive ENTRAMI technique offers the possibility to combine nerve release with pudendal neuromodulation. CONCLUSIONS: Pudendal and inferior cluneal nerve entrapment syndrome are a challenge not only for diagnosis but also for treatment. Different non-invasive and invasive treatment options exist and should be offered in a pluri-disciplinary setting.

The application of pudendal nerve blockade in the treatment of pudendal neuralgia related chronic pelvic pain / Nervus pudendus idegblokád alkalmazása krónikus kismedencei fájdalmat okozó pudendusneuralgia kezelésében

Pudendal neuralgia is a rare and ­ in the absence of somatic, radiological and laboratory abnormalities ­ often unrec-ognizable problem, posing a serious challenge to therapeutic management. Our case study presents the complete diagnostic and therapeutic algorithm of a female patient with chronic pudendal pain. In addition, our paper draws attention to the role of pelvic pain workgroups ­ such as the Pelvic Pain Task Force of the Semmelweis University ­ where cases of chronic pelvic pain with no clear medical reason can be assessed and treated with higher efficiency.

Transvaginal pudendal nerve blocks in patients with pudendal neuralgia: 2-year follow-up results.

PURPOSE: Pudendal neuralgia (PN) is an extremely painful neuropathy of the pudendal nerve resulting in a negative impact on a patient's quality of life. The aim of this study is to evaluate the 2-year outcomes of repetitive doses of the transvaginal pudendal nerve injections (PNI), and to compare the success of the PNI concerning anatomical levels (endopelvic and extrapelvic portion) of the pudendal nerve pathology. METHODS: This retrospective longitudinal cohort study consists of patients with PN diagnosed with the first four essential Nantes criteria. Diagnostic PNI was performed on 67 patients to fulfill the fifth criteria of Nantes. A total of 56 patients who responded to the initial diagnostic PNI underwent therapeutic repeated transvaginal PNIs twice for 3 weeks apart. Mean pain intensity scores were measured using a visual analog scale at the 1st, 3rd, 6th, 12th, and 24th months after the therapeutic blocks were completed. Effectiveness of the PNIs' was defined as ≥ 50% improvement of the initial pain, and relative improvement was defined as 30-50% improvement of the initial pain. Treatment failure was defined as the reduction of the initial pain by less than 30% or the return of the pain to its worst condition. RESULTS: The efficacy of the PNIs significantly declined over time. Pudendal nerve blocks provided a significant decrease in pain scores; however, this decrease lost its strength significantly in the 24th month. The intervention was more effective in entrapments of the pudendal nerve between sacrospinous and sacrotuberous ligaments or below (Level-2) when compared to the injuries in the endopelvic part (Level-1). More than 50% pain reduction continued in five patients with pathology at Level-1 and 24 patients with pathology at Level-2. CONCLUSION: Repeated PNIs could provide a significant decrease in pain scores for both short- and long-term periods. However, the efficacy of the PNIs declined over 2 years. The success of PNIs may be affected by the anatomical level of the nerve injury; therefore, interligamentous pudendal nerve entrapment cases have more benefits than the cases of pudendal nerve entrapment in the endopelvic part. However, it is recommended to perform therapeutic nerve blocks even in patients with suspected endopelvic pudendal nerve pathology before the referral to surgery.

Recommendations on the management of pudendal nerve entrapment syndrome: A formalised expert consensus.

BACKGROUND: Since the development and publication of diagnostic criteria for pudendal nerve entrapment (PNE) syndrome in 2008, no comprehensive work has been published on the clinical knowledge in the management of this condition. The aim of this work was to develop recommendations on the diagnosis and the management of PNE. METHODS: The methodology of this study was based on French High Authority for Health Method for the development of good practice and the literature review was based on the PRISMA method. The selected articles have all been evaluated according to the American Society of Interventional Pain Physicians assessment grid. RESULTS: The results of the literature review and expert consensus are incorporated into 10 sections to describe diagnosis and management of PNE: (1) diagnosis of PNE, (2) patients advice and precautions, (3) drugs treatments, (4) physiotherapy, (5) transcutaneous electrostimulations (TENS), (6) psychotherapy, (7) injections, (8) surgery, (9) pulsed radiofrequency, and (10) Neuromodulation. The following major points should be noted: (i) the relevance of 4+1 Nantes criteria for diagnosis; (ii) the preference for initial monotherapy with tri-tetracyclics or gabapentinoids; (iii) the lack of effect of opiates, (iv) the likely relevance (pending more controlled studies) of physiotherapy, TENS and cognitive behavioural therapy; (v) the incertitudes (lack of data) regarding corticoid injections, (vi) surgery is a long term effective treatment and (vii) radiofrequency needs a longer follow-up to be currently proposed in this indication. CONCLUSION: These recommendations should allow rational and homogeneous management of patients suffering from PNE. They should also allow to shorten the delays of management by directing the primary care. SIGNIFICANCE: Pudendal nerve entrapment (PNE) has only been known for about 20 years and its management is heterogeneous from one practitioner to another. This work offers a synthesis of the literature and international experts' opinions on the diagnosis and management of PNE.

Post-traumatic double crush pudendal nerve entrapment syndrome after fracture of the pelvis: A case report.

Pudendal syndrome is primarily characterized by stress urinary incontinence, dysuria, sexual arousal syndrome, painful erections, and anal incontinence. The syndrome occurs when the pudendal nerve or one of its branches is compressed, stretched, or injured. Double crush is the compression of a peripheral nerve at two or more separate areas with various signs and symptoms. We, herein, aimed to introduce the case of a 42-year-old male who underwent the distal release procedure due to the diagnosis of "double crush pudendal syndrome" following a proximal release surgery previously performed elsewhere. The patient's history revealed a pelvic fracture with urethral injury 27 years ago. Throughout the years, the patient had been evaluated by various medical disciplines and undergone several treatments. In 2017, an orthopedic surgeon performed proximal pudendal nerve release using transgluteal approach, and then rectal pain and defecation complaints relieved. However, in 2019, the patient was referred to our clinic because of the persistence of erection and perineal complaints after the proximal pudendal nerve release. Based on a detailed clinical and laboratory assessment, the diagnosis of double crush neuropathy was established, and distal release of the pudendal nerve using transperineal approach was performed. To determine the efficiency of the surgical treatment, International Index of Erectile Function (IIEF) and Quality of Erection Questionnaire (QAQ) tests were used preoperatively and at the first postoperative year. Furthermore, to assess the perineal pain, erection pain, and pain during intercourse Visual Analog Scale (VAS) was used. The erectile dysfunction improved from the severe degree (9 points) to the mild degree (22 points) postoperatively. The patient's general and sexual satisfaction scores, and erection quality score improved compared to the preoperative baseline. According to VAS, the perineal pain, erectile pain,and pain during intercourse decreased postoperatively. (from 7 to 2 out of 10, from 8 to 3 out of 10, from 7 to 2 out of 10, respectively). When perineal and sexual complaints are encountered following pelvic trauma, the pudendal nerve-related problems, especially double crush syndrome, should be kept in mind in differential diagnosis. A multidisciplinary approach must be established in order to avoid any delay in diagnosis and treatment. Surgical intervention may provide a significant improvement in clinical and functional status.

Diagnostic and therapeutic algorithm for pudendal nerve entrapment syndrome. / Algoritmo diagnóstico y terapéutico del síndrome de atrapamiento del nervio pudendo.

Pudendal nerve entrapment syndrome is widely unknown and often misdiagnosed or confused with other pelvic floor diseases. The aim is to develop a diagnostic and therapeutic algorithm based on a review of the existing literature. For its diagnosis, an anamnesis will be carried out in search of possible aetiologies, surgical history, and history of pain, assessing location and irradiation, intensity on the visual analogue scale, timing, triggering factors and rule out alarm signs. A physical examination will be performed, looking for trigger points or areas of fibrosis with transvaginal / transrectal palpation of the terminal branches of the nerve. With a doubtful diagnosis, an anaesthetic block of the pudendal nerve can be performed. Once the diagnosis is confirmed, the treatment will begin staggered with lifestyle changes, drug therapy and physiotherapy. In view of the failure of these measures, invasive therapies such as botulinum toxin injection, pulsed radiofrequency and decompression surgery or spinal cord stimulation will be used.

Dynamic transperineal ultrasonography correlates with prolonged pudendal nerve latency in female with fecal incontinence.

The pelvic floor is a complex anatomical entity and its neuromuscular assessment is evaluated through debated neurophysiological tests. An innovative approach is the study of pelvic floor through dynamic transperineal ultrasound (DTU). The aim of this study is to evaluate DTU sensitivity in recognizing patients with fecal incontinence and to evaluate its concordance with the results of the motor latency studied via pudendal nerve terminal motor latency (PNTML). Female patients affected by FI addressed to our center of coloproctology were prospectively assessed. After a coloproctological evaluation, comprising the PNTML assessment to identify pudendal neuropathy, patients were addressed to DTU to determine anterior and posterior displacement of puborectalis muscle by a blinded coloproctologist. In order to compare the data, a cohort of female healthy volunteers was enrolled. Sixty-eight subjects (34 patients and 34 healthy volunteers) were enrolled. The sensitivities of anterior displacement, posterior displacement and either anterior or posterior displacement in determining the fecal incontinence were 82%, 67% and 91%, respectively. A further high correlation of either anterior or posterior displacement with PTNML was also noted (88%). DTU is an indirect, painless and reproducible method for the identification of the pelvic floor neuromuscular integrity. Its findings seem to highly correlate with FI symptoms and with PNTML results. In the near future, after larger comparative studies, DTU would be considered a potential reliable non-invasive and feasible indirect procedure in the identification of fecal incontinence by pudendal neuropathy. Trial registration number is NCT03933683.

Estimate of the proportion of uncertain diagnoses of pudendal neuralgia in women with chronic pelvic-perineal pain: A systematic review with a descriptive data synthesis.

BACKGROUND: There is a gap between pudendal neuralgia (PN) due to pudendal entrapment syndrome and PN without pudendal entrapment syndrome. The latter could have atypical symptoms. AIM: Defining a rate of atypical PN from a clinical series of female patients with chronic pelvic-perineal pain. METHODS: The atypical PN was defined as a pain not meeting clinical criteria for pudendal entrapment syndrome. The effect size was the rate of atypical PN. Such a rate was expected to be found among patients screened for enrollment in clinical series on pudendal neuropathic pain. A systematic search was performed looking for clinical series on PN. Studies must report information on female patients, pelvic-perineal pain, at least a clinical criterion for diagnosing the pudendal neurogenic origin of pain, the proportion of patients with pain not meeting the clinical criterion/a for diagnosing the pudendal entrapment pain. RESULTS: From 2637 references, nine studies were included for qualitative analysis. Three of them were not suitable for data synthesis: one assessed the rate of PN after hip arthroscopy; second enrolled miscellaneous patients, a third investigated patients with gynecological diseases. Six studies involved patients with suspicion of pudendal entrapment symptoms (205 patients observed), allowing data synthesis. One of these series was judged as being of good quality. The overall rate of atypical PN is 0.013 (95% confidence interval, 0.008-0.021), I2 0%. Further analysis suggests the risk of bias for all studies. CONCLUSIONS: Atypical PN in females is low when clinical criteria for pudendal entrapment syndrome are applied.

A minimally invasive, endoscopic transgluteal procedure for pudendal nerve and inferior cluneal nerve neurolysis in case of entrapment: 3- and 6-month results. The ENTRAMI technique for neurolysis.

BACKGROUND: Pudendal and cluneal nerve entrapment can cause a neuropathic pain syndrome in the sensitive areas innervated by these nerves. Recently, a new endoscopic minimal invasive approach for pudendal and inferior cluneal nerve neurolysis has been published in a cadaver study. The aim of our study was to describe the feasibility of this new approach and to evaluate the clinical outcome. METHODS: Fifteen patients underwent the ENTRAMI technique. The Numeric Pain Rating Scale (NPRS) and Patient Global Impression of Change (PGIC) were recorded at baseline and at 3 and 6 months after surgery. RESULT: The average duration of intervention (skin to skin) was 139 min (range 50-270 min) for bilateral pudendal neurolysis and/or cluneal neurolysis and 113 min (range 100-130 min) for unilateral pudendal and/or cluneal neurolysis. No perioperative blood loss occurred. At 3 months, 50% of patients declared a more than 30% improvement of their PGIC, increasing to 57% at 6 months; 31% reported more than 90% improvement of PGIC at 6 months. Overall reduction of the average maximal NPRS score was from 9 (range 7-10) to 6 at 3 months (range 0-10; p value < 0.05) and to 5 at 6 months (range 0-10; p value < 0.05). There were no postoperative complications. CONCLUSIONS: The ENTRAMI technique is feasibly in patients suffering from pudendal and/or cluneal neuralgia and preliminary results are promising. CLINICAL TRIAL NUMBER: NCT03883178.

A Novel Approach to Managing Post Retropubic Vaginal Sling Pain.

OBJECTIVE: To describe a novel technique of using peripheral nerve neuromodulation (PNNM) for the treatment of refractory, mesh-induced chronic pelvic pain. Chronic pelvic pain associated with mesh can be a debilitating complication and there is currently no consensus on treatment. PNNM has been shown to be successful in the treatment of post-traumatic neuralgias but has yet to be studied in mesh complications. MATERIALS AND METHODS: We present a case of a 50-year-old woman who had unrelenting pelvic pain after retropubic sling placement. She failed multiple therapies including medications, mesh removal, pelvic floor physical therapy, pudendal neuromodulation, and pelvic floor onabotulinumtoxinA trigger point injections. RESULTS: The only treatment that provided temporary relief of this patient's pain was transvaginal trigger point injections along with a right pudendal nerve block using 40 mg triamcinolone and 0.5% ropivacaine. To help define if treatment at the site of her pain would provide relief, a series of blocks were done by advancing a needle retropubically to her area of pain and injecting triamcinolone and 0.5% ropivacaine. This injection, which corresponded to the previous tract of her retropubic sling, provided temporary, but profound, relief. PNNM was then done with placement of the electrode in the retropubic space at the site of her pain. This provided instantaneous relief of almost all of her pain symptoms. Twelve months postoperatively, the patient continued to have >90% improvement in her pain. CONCLUSION: Focused PNNM is a simple procedure and can provide symptomatic relief for refractory postvaginal mesh pain.

[Mechanisms of formation and diagnosis of tunnel pudendal neuropathy]. / Mekhanizmy formirovaniia i diagnostika tunnel'nykh pudendoneiropatii.

The article contains information on the most common causes of lesions of the pudendal nerve - tunneling neuropathy. The author considers a set of the Nantes diagnostic criteria for pudendal neuralgia and presents a brief differential diagnosis of pelvic neuropathies. A case of Tinel's pudandal symptom with interligamentous compressions is described. The causes of the low diagnosability of pudendal neuropathy are analysed.

Successful Treatment of Penile Numbness and Erectile Dysfunction Resulting From Pudendal Nerve Entrapment.

Pudendal nerve decompression surgery has not been studied or reported for the treatment of penile numbness in the absence of pain. Herein, we report a case of a male patient with chronic numbness of the penis and erectile dysfunction in the absence of pelvic pain who was found to have pudendal nerve entrapment. This patient was treated with surgical decompression of the pudendal nerves that resulted in the return of genital sensation and erections. Thus, we propose that pudendal nerve entrapment may be considered as a cause of penile numbness and that pudendal nerve decompression surgery in these patients may be effective.

Role of 3 Tesla MR Neurography and CT-guided Injections for Pudendal Neuralgia: Analysis of Pain Response.

BACKGROUND: Magnetic resonance neurography (MRN) has an increasing role in the diagnosis and management of pudendal neuralgia, a neurogenic cause of chronic pelvic pain. OBJECTIVE: The objective of this research was to determine the role of MRN in predicting improved pain outcomes following computed tomography (CT)-guided perineural injections in patients with pudendal neuralgia. STUDY DESIGN: This study used a retrospective cross-sectional study design. SETTING: The research was conducted at a large academic hospital. METHODS: Patients: Ninety-one patients (139 injections) who received MRN and CT-guided pudendal blocks were analyzed. INTERVENTION: A 3Tesla (T) scanner was used to evaluate the lumbosacral plexus for pudendal neuropathy. Prior to receiving a CT-guided pudendal perineural injection, patients were given pain logs and asked to record pain on a visual analog scale. MEASUREMENT: MRN findings for pudendal neuropathy were compared to the results of the CT-guided pudendal nerve blocks. Injection pain responses were categorized into 3 groups - positive block, possible positive block, and negative block.Statistical Tests: A chi-square test was used to test any association, and a Cochran-Armitage trend test was used to test any trend. Significance level was set at .05. All analyses were done in SAS Version 9.4 (SAS Institute, Inc., Cary, NC). RESULTS: Ninety-one patients (139 injections) who received MRN were analyzed. Of these 139 injections, 41 were considered positive (29.5%), 52 of 139 were possible positives (37.4%), and 46 of 139 were negative blocks (33.1%). Of the patients who had a positive pudendal block, no significant difference was found between the MRN result and the pudendal perineural injection response (P = .57). Women had better overall response to pudendal blocks, but this response was not associated with MRN findings (P = .34). However, positive MRN results were associated with better pain response in men (P = .005). Patients who reported bowel dysfunction also had a better response to pudendal perineural injection (P = .02). LIMITATIONS: Some limitations include subjectivity of pain reporting, reporting consistency, absence of a control group, and the retrospective nature of the chart review. CONCLUSION: Pudendal perineural injections improve pain in patients with pudendal neuralgia and positive MRN results are associated with better response in men. KEY WORDS: MRI, MRN, CT injection, pudendal neuralgia, pudendal nerve, pelvic pain, chronic pelvic pain, pudendal neuropathy.

Persistent Abdominal Pain 2 Years After Cesarean Delivery.

A 29-year-old multiparous patient is referred for chronic lower abdominal pain radiating into her groin since undergoing cesarean delivery 2-years previously. Laboratory and radiographic evaluation results are negative. She asks you, "Please tell me, why am I having this pain?"

Role of nerve block as a diagnostic tool in pudendal nerve entrapment.

BACKGROUND: Pudendal nerve entrapment is a disabling condition which is difficult to diagnose and treat. Nantes criteria include the requirement of positive anaesthetic pudendal nerve block that is widely used to allow identification of patients likely to benefit from the definitive but invasive pudendal nerve release. This study aimed to determine if pudendal nerve blockade under general anaesthesia could diagnose and temporarily treat pudendal nerve entrapment in patients suffering from chronic pelvic/perineal pain and/or organ dysfunction. METHODS: This retrospective analysis of a prospectively maintained database examined the outcomes of all recipients of diagnostic pudendal nerve block in a quaternary referral centre between 2012 and 2017. Primary outcome was relief of perineal pain (transient or permanent). Secondary outcomes were demographics, referral patterns for definitive procedure and complication rates. Statistical analysis was performed using SPSS v 24. RESULTS: A total of 77 patients were included in the study. Mean age was 57.27 ± 13.55 years. Majority were females (n = 62, 80.5%). Relief of pain was experienced by 47 of 76 (68.1%) patients after initial injection. Complication rate of injection was 3.9% (n = 3) which in all cases was unilateral lower limb paraesthesia. Of the 37 patients (52.9%) referred, 20 underwent surgical decompression with 12 (60%) being successful. CONCLUSION: Pudendal nerve injection is a safe and simple procedure that can provide accurate diagnosis and transient relief from this chronic and debilitating problem. This technique helps to isolate patients suitable for pudendal nerve decompression which offers high success rates.

Correlation between Anatomical Segments of the Pudendal Nerve and Clinical Findings of the Patient with Pudendal Neuralgia.

BACKGROUND: The objective was to describe clinical findings and outcomes of patients with pudendal neuralgia in relation with the anatomical segment affected. METHODS: Fifty-one consecutive patients with chronic perineal pain (CPP) located in the areas supplied by the pudendal nerve (PN), from January 2011 to June 2012, were analyzed. RESULTS: The distribution of pain at perineal, dorsal clitoris and inferior anal nerves was 92.2, 31.4 and 25.5% respectively. The duration of pain was longer when the dorsal clitoris nerve (DCN) was affected (p < 0,003). The pain in the pudendal canal was frequently associated with the radiation of pain to the inferior members (p < 0.043). CONCLUSION: CPP and radiation of pain to lower limbs suggest a disorder at the second segment of PN. A positive Tinel sign in the third segment indicates a nerve entrapment. In terminal branches, pain was more frequent at the perineal nerve and more persistent at the DCN.

Nerve entrapment syndromes in dermatology: Review and practical approach to treatment.

A good understanding of cutaneous nerve entrapment syndromes is important for physicians to provide early and accurate diagnosis and treatment. These syndromes have traditionally been managed with analgesics, antidepressants or antiepileptic medication but this approach is often inadequate and causes frequent adverse medication effects. With early diagnosis and treatment, many nerve entrapment syndromes can be successfully managed with physical, non-pharmacological approaches including stretches, exercises and physiotherapy.

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.

Injury to the perineal branch of the pudendal nerve in men: Outcomes from surgical resection of the perineal branches.

OBJECTIVE: The objective is to report the outcome of an anterior surgical approach to treat neuroma of the perineal branch of the pudendal nerve (PBPN). PATIENTS AND METHODS: An IRB-approved prospective study enrolled 14 consecutive male patients from 2011 through 2015 who had symptoms of perineal/scrotal pain. Each patient had a successful, diagnostic, pudendal nerve block. The surgical procedure was resection of the PBPN and implantation of the nerve into the obturator internus muscle. Mean age at surgery was 50 ± 15 years. Median duration of pain symptoms was 5.5 years (range 1.2-42.9 years). Mechanisms of injury was exercise (6/14), prostatectomy (4/14), and falls (4/14). Outcomes were the Male Pudendal Pain Functional Questionnaire (MQ), and the Numeric Pain Rating Scale (NPRS). RESULTS: The mean postoperative follow-up was 26 ± 14 months. The MQ demonstrated that after surgery, patients overall had significantly less disability due to pudendal pain (P < .03). The NPRS revealed that pain significantly improved (P < .004). CONCLUSIONS: Resection of the PBPN and implantation of this nerve into the obturator internus muscle significantly relieved men's pelvic pain disability.

[Pudendal neuralgia diagnosed by electrophysiological examination].

A 62-year-old man with suspected pudendal neuralgia was admitted to a department of clinical neurophysiology for examination. The patient had experienced increasingly altered sensations in the groin, particularly in form of pain in a sitting position. The neurophysiological studies substantiated the suspicion. Pudendal neuralgia is a painful neuropathic condition. The most frequent cause is entrapment of the pudendal nerve in the pelvis. The diagnosis is made clinically by using Nantes criteria, and neurophysiological studies of the perineum are important supplements when pudendal nerve entrapment is suspected.