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.

Description and classification of postpartum chronic pain: A multicentric prospective study.

INTRODUCTION: To classify persistent perineal and pelvic postpartum pain using the classification usually employed in chronic pelvic pain. MATERIAL AND METHOD: Prospective observational study including all women who have consulted an algologist or gynecologist at one of the six French centers for a chronic pain (superior or equal to 3 months) spontaneous linked by the mother with her childbirth were included. During semi-directed interviews, a questionnaire regarding sociodemographic factors and detailed questions about pain were collected. Then, pelvic and perineal pain were classified into 7 pain syndromes: pelvic sensitization (Convergences PP criteria), complex regional pain syndrome (Budapest criteria), pudendal or cluneal neuralgia (Nantes criteria), neuroma, thoraco-lumbar junction syndrome, myofascial pain (muscle trigger zone), fibromyalgia (American College of Rheumatology criteria). The principal objective of this study is to assess the prevalence of each painful disorder. The secondary aims were the description of socio-demographic factors and clinical characteristics of this population, identify the related symptoms and the impact on daily function associated with the chronic pelvic or perineal postpartum pain. RESULTS: 40 women with chronic pelvic or perineal pain spontaneously linked with childbirth were included. 78 % experienced pain for more than 12 months. A large majority had a vaginal birth (95 %) with perineal suture (90 %) and severe acute pain within the first week postpartum (62 %). Postpartum pain impacted participant's sexual activity (80 %), micturition (28 %) and defecation (38 %). In the sample, 17 cases of neuroma, 6 patients with pudendal or cluneal neuralgia, 13 patients with pelvic sensitization and 2 cases of fibromyalgia were identified. Complex regional pain syndrome was diagnosed in 8 patients, and myofascial pain in 11 women, and only 1 patient had thoraco-lumbar junction syndrome. Neuropathic pain was found in 31 participants (77.5 %) according to DN4 criteria. DISCUSSION: The classification scheme proposed in this study may be a very useful tool to investigate postpartum pelvic and perineal pain and to propose a treatment.

Clinical Criteria of Central Sensitization in Chronic Pelvic and Perineal Pain (Convergences PP Criteria): Elaboration of a Clinical Evaluation Tool Based on Formal Expert Consensus.

Background: The evaluation of chronic pelvic and perineal pain (CPP) is often complex. The patient's description of the pain often appears to be disproportionate to the limited findings on physical examination and/or complementary investigations. The concept of central sensitization may allow better understanding and management of patients with CPP. Objective: The aim of this study was to elaborate a clinical evaluation tool designed to simply identify sensitization in pelvic pain. Methods: A list of 63 items was submitted to 22 international CPP experts according to the Delphi method. Results: Ten clinical criteria were adopted for the creation of a clinical evaluation tool: 1) pain influenced by bladder filling and/or urination, 2) pain influenced by rectal distension and/or defecation, 3) pain during sexual activity, 4) perineal and/or vulvar pain in response to normally nonpainful stimulation, 5) pelvic trigger points (e.g., in the piriformis, obturator internus, and/or levator ani muscles), 6) pain after urination, 7) pain after defecation, 8) pain after sexual activity, 9) variable (fluctuating) pain intensity and/or variable pain distribution, 10) migraine or tension headaches and/or fibromyalgia and/or chronic fatigue syndrome and/or post-traumatic stress disorder and/or restless legs syndrome and/or temporomandibular joint dysfunction and/or multiple chemical sensitivity. Conclusions: This process resulted in the elaboration of a clinical evaluation tool designed to identify and appropriately manage patients with CPP comprising a sensitization component.

Place of surgery in the management of post-operative chronic pain after placement of prosthetic material based on a series of 107 cases.

AIMS: The objective of this study was to evaluate the efficacy of surgical removal of prosthetic material, possibly combined with nerve release, on chronic postoperative pain following placement of prosthetic material. MATERIAL AND METHODS: Single-tertiary-centre study on 107 patients managed between November 2004 and April 2016 for removal of prosthetic material responsible for postoperative chronic pain: retropubic suburethral sling (n = 32), transobturator suburethral sling (n = 50), prolapse mesh (n = 16), and hernia mesh (n = 9). The primary endpoint was at least 50% reduction of pain evaluated by a pain numerical rating scale (NRS). RESULTS: The mean interval between the initial operation involving placement of prosthetic material and reoperation for removal of prosthetic material was 41.2 ± 35.4 months. In all cases pain apperaed immediately following prosthetic material placement surgery. Pain presented neuropathic features in almost 30% of cases and was poorly systematized in more than one-half The mean follow-up of the study population was 8.4 ± 10.3 months. The mean pain NRS score for the overall population was seven preoperatively and three at last follow-up. At least 50% reduction of the pain NRS score was observed 67% of cases at last follow-up. During follow-up, 45% of patients experienced relapse of the disorder for which the prosthetic material was initially placed with, in particular, a 62% recurrence rate of urinary incontinence after removal of transobturator suburethral tape. CONCLUSION: Surgical removal of prosthetic material to treat chronic postoperative pain, achieved global improvement of pain in about two-thirds of cases, but with a risk of recurrence of the initial disorders.

Anatomical Variants of the Pudendal Nerve Observed during a Transgluteal Surgical Approach in a Population of Patients with Pudendal Neuralgia.

BACKGROUND: Several studies have described the course and anatomical relations of the pudendal nerve. Several surgical nerve decompression techniques have been described, but only the transgluteal approach has been validated by a prospective randomized clinical trial. The purpose of this study was to describe the course of the nerve and its variants in a population of patients with pudendal neuralgia in order to guide the surgeon in the choice of surgical approach for pudendal nerve decompression. OBJECTIVES: In order to support the choice of the transgluteal approach, used in our institution, we studied the exact topography, anatomical relations, and zones of entrapment of the pudendal nerve in a cohort of operated patients. STUDY DESIGN: Observational study. SETTING: University hospital. METHODS: One hundred patients underwent unilateral or bilateral nerve decompression performed by a single operator via a transgluteal approach. All patients satisfied the Nantes criteria for pudendal neuralgia. The operator meticulously recorded zones of entrapment, anatomical variants of the course of the nerve, and the appearance of the nerve in the operative report. RESULTS: One hundred patients and 145 nerves were operated consecutively. Compression of at least one segment of the pudendal nerve (infrapiriform foramen, ischial spine, and Alcock's canal) was observed in 95 patients. The zone of entrapment was situated at the ischial spine between the sacrospinous ligament (or ischial spine) and the sacrotuberous ligament in 74% of patients.Anatomical variants were observed in 13 patients and 15 nerves. Seven patients presented an abnormal transligamentous course of the nerve (sacrotuberous or sacrospinous). A perineal branch of the fourth sacral nerve to the external anal sphincter was identified in 7 patients. In this population of patients with pudendal neuralgia, the pudendal nerve was stenotic in 27% of cases, associated with an extensive venous plexus that could make surgery more difficult in 25% of cases, and the nerve had an inflammatory appearance in 24% of cases. LIMITATIONS: We obviously cannot be sure that the anatomical variants identified in this study can be extrapolated to the general population, as our study population was composed of patients experiencing perineal pain due to pudendal nerve entrapment and their pain could possibly be related to these anatomical variants, especially a transligamentous course of the pudendal nerve. The absence of other prospective randomized clinical trials evaluating other surgical approaches also prevents comparison of these results with those of other surgical approaches. CONCLUSIONS: This is the first study to describe the surgical anatomy of the pudendal nerve in a population of patients with pudendal neuralgia. In more than 70% of cases, pudendal nerve entrapment was situated in the space between the sacrospinous ligament and the sacrotuberous ligament. Anatomical variants of the pudendal nerve were also observed in 13% of patients, sometimes with a transligamentous course of the nerve. In the light of these results, we believe that a transgluteal approach is the most suitable surgical approach for safe pudendal nerve decompression by allowing constant visual control of the nerve.Key words: Surgical, operative technique, pudendal, neuralgia, transgluteal approach.

Pudendal Neuralgia Due to Pudendal Nerve Entrapment: Warning Signs Observed in Two Cases and Review of the Literature.

Pudendal neuralgia is a chronic neuropathic pelvic pain that is often misdiagnosed and inappropriately treated. The Nantes criteria provide a basis for the diagnosis of pudendal neuralgia due to pudendal nerve entrapment. The 5 essential diagnostic criteria are pain situated in the anatomical territory of the pudendal nerve, worsened by sitting, the patient is not woken at night by the pain, and no objective sensory loss is detected on clinical examination. The fifth criterion is a positive pudendal nerve block. We have also clarified a number of complementary diagnostic criteria and several exclusion criteria that make the diagnosis unlikely. When pudendal neuralgia due to pudendal nerve entrapment is diagnosed according to the Nantes criteria, no further investigation is required and medical or surgical treatment can be proposed. Nevertheless, a number of warning signs suggesting other possible causes of pudendal neuralgia must not be overlooked. These warning signs (red flags) are waking up at night, excessively neuropathic nature of the pain (for example, associated with hypoesthesia), specifically pinpointed pain, which can suggest neuroma and pain associated with neurological deficit. In these atypical presentations, the diagnosis of pain due to pudendal nerve entrapment should be reconsidered and a radiological examination should be performed. The 2 cases described in this report (tumor compression of the pudendal nerve) illustrate the need to recognize atypical pudendal neuralgia and clarify the role of pelvic magnetic resonance imaging (MRI), as MRI provides very valuable information for the evaluation of diseases involving the ischiorectal fossa. The presence of red flags must be investigated in all cases of pudendal neuralgia to avoid missing pudendal neuralgia secondary to a mechanism other than nerve entrapment.

New concepts on functional chronic pelvic and perineal pain: pathophysiology and multidisciplinary management.

The management of chronic pelvic and perineal pain has been improved by a better understanding of the mechanisms of this pain and an optimized integrated multidisciplinary approach to the patient. The concept of organic lesions responsible for a persistent nociceptive factor has gradually been replaced by that of dysregulation of nociceptive messages derived from the pelvis and perineum. In this setting, painful diseases identified by organ specialists are usually also involved and share several common denominators (triggering factors, predisposing clinical context). These diseases include painful bladder syndrome, irritable bowel syndrome, vulvodynia, and chronic pelvic pain syndrome. The painful symptoms vary from one individual to another and according to his or her capacity to activate pain inhibition/control processes. Although the patient often attributes chronic pain to a particular organ (with the corollary that pain will persist until the organ has been treated), this pain is generally no longer derived from the organ but is expressed via this organ. Several types of clinical presentation of complex pelvic pain have therefore been pragmatically identified to facilitate the management of treatment failures resulting from a purely organ-based approach, which can also reinforce the patient's impression of incurability. These subtypes correspond to neuropathic pain, central sensitization (fibromyalgia), complex regional pain syndrome, and emotional components similar to those observed in post-traumatic stress disorder. These various components are also often associated and self-perpetuating. Consequently, when pelvic pain cannot be explained by an organ disease, this model, using each of these four components associated with their specific mechanisms, can be used to propose personalized treatment options and also to identify patients at high risk of postoperative pelvic pain (multi-operated patients, central sensitization, post-traumatic stress disorder, etc.), which constitutes a major challenge for prevention of these types of pain that have major implications for patients and society.

Interest of repetitive transcranial magnetic stimulation of the motor cortex in the management of refractory cancer pain in palliative care: Two case reports.

BACKGROUND: Non-drug treatments should be systematically associated to the medical analgesic treatment during the terminal phase of cancer. CASES PRESENTATION: Patient 1, a 23-year-old woman, presented an adenocarcinoma of the rectum, with liver and lung metastases. Pain was initially treated by oral morphine and a combination of pregabalin and amitriptyline. Ketamine and intrathecal administration of morphine were both ineffective. Patient 2, a 69-year-old woman, presented a cutaneous T-cell lymphoma. She was admitted to the palliative care unit with mixed pain related to cutaneous lymphomatous infiltration. World Health Organization (WHO) step 3 analgesics had not been tolerated. CASES MANAGEMENT: Both patients received five consecutive 20-min sessions of repetitive transcranial magnetic stimulation to the right motor cortex. CASES OUTCOME: Patient 1 experienced a marked improvement of her pain over the days following the first repetitive transcranial magnetic stimulation session. Medical treatment was able to be rapidly decreased by about 50%, which restored an almost normal level of consciousness and lucidity. Patient 2's pain was also markedly decreased over the days following these five consecutive sessions, and repetitive transcranial magnetic stimulation also appeared to have had a beneficial effect on the patient's anxiety and mood. CONCLUSION: In the context of palliative care of cancer patients experiencing refractory pain that is difficult to control by the usual treatments, motor cortex repetitive transcranial magnetic stimulation, due to its noninvasive nature, can be used as an adjuvant therapy to improve various components of pain, including the emotional components. By reducing the doses of analgesics, repetitive transcranial magnetic stimulation decreases the severity of their adverse effects and improves the patient's quality of life.

Spinal cord stimulation of the conus medullaris for refractory pudendal neuralgia: a prospective study of 27 consecutive cases.

AIMS: Thirty percent of patients with pudendal neuralgia due to pudendal nerve entrapment obtain little or no relief from nerve decompression surgery. The objective was to describe the efficacy of spinal cord stimulation of the conus medullaris in patients with refractory pudendal neuralgia. METHODS: This prospective study, conducted by two centers in the same university city, described the results obtained on perineal pain and functional disability in all patients with an implanted conus medullaris stimulation electrode for the treatment of refractory pudendal neuralgia. Twenty-seven consecutive patients were included by a multidisciplinary pelvis and perineal pain clinic between May 2011 and July 2012. Mean follow-up was 15 months. The intervention was an insertion of a stimulation electrode was followed by a test period (lasting an average of 13 days) before deciding on permanent electrode implantation. Maximum and average perineal pain scores and the pain-free sitting time were initially compared during the test and in the long-term (paired t-test). The estimated percent improvement (EPI) was evaluated in the long-term. RESULTS: Twenty of the 27 patients were considered to be responders to spinal cord stimulation and 100% of implanted patients remained long-term responders (mean tripling of sitting time, and mean EPI of 55.5%). CONCLUSIONS: Spinal cord stimulation of the conus medullaris is a safe and effective technique for long-term treatment of refractory pudendal neuralgia. Routine use of this technique, which has never been previously reported in the literature in this type of patient, must now be validated by a larger scale study.

Validation of voiding diary for stratification of bladder pain syndrome according to the presence/absence of cystoscopic abnormalities: a two-centre prospective study.

OBJECTIVE: To assess the value of the voiding diary in the management of patients with bladder pain syndrome for predicting the presence or absence of cystoscopic abnormalities. PATIENTS AND METHODS: From November 2009 to March 2011, 54 consecutive patients (39 women and 15 men) with bladder pain syndrome, as defined by the European Society for the Study of Interstitial Cystitis/Bladder Pain Syndrome (ESSIC) criteria, were prospectively enrolled in this two-centre study. All patients completed a home voiding diary on 3 consecutive days, which included analysis of voiding frequency, voided volume and severity of pre- and post-voiding pain. The variables were evaluated on a numeric pain scale (NPS). All patients then underwent standardized cystoscopy under anaesthesia. Patients were stratified into two groups: a group with or a group without cystoscopic abnormalities. Voiding diary variables were compared using Student's t-test. RESULTS: Cystoscopic abnormalities were found in 33 patients. The group of patients with cystoscopic abnormalities had significantly more severe frequency (P = 0.034), especially nocturnal frequency (P = 0.009), a significantly lower mean voiding volume and lower sd from the mean (P = 0.011 and P = 0.014), and a significantly lower mean post-voiding NPS score (P = 0.039). CONCLUSION: On analysis of the voiding diaries, we found that different patient profiles were associated with the cystoscopic appearance of the bladder. A clinical voiding score was proposed to predict the cystoscopic appearance of the bladder on the basis of the voiding diary in bladder pain syndrome but needs to be validated on an independent population.

Pelvic schwannoma: robotic laparoscopic resection.

BACKGROUND: Schwannoma is a rare benign tumor of peripheral nerves arising from Schwann cells of the ubiquitous nerve sheath. OBJECTIVE: To describe the operative steps and technical aspects of robotic laparoscopic resection of pelvic schwannoma. METHODS: We describe 2 patients with pelvic schwannoma: a 34-year-old woman with schwannoma of the right lumbosacral trunk and a 58-year-old woman with schwannoma of a left S1 nerve. Pain was the main symptom in both patients. The diagnosis was confirmed by magnetic resonance imaging and nerve biopsies. Both patients were operated on by robotic laparoscopy. RESULTS: Lesions were totally enucleated after incising the epineurium. After dissection of the schwannoma, the vascular pedicle and nerve fascicles involved were identified, coagulated, and then sectioned. The remaining fascicles of the nerve were preserved. The postoperative course was uneventful in both patients. With follow-up of 9 and 13 months, both patients obtained complete pain relief with no neurological sequelae. CONCLUSION: Robotic laparoscopic resection of pelvic nerve tumors such as schwannomas is technically feasible.

Is section of the sympathetic rami communicantes by laparoscopy in patients with refractory low back pain efficient?

OBJECTIVE: The objective of this prospective innovative treatment is to section the pain pathways carried by sympathetic lumbar rami communicantes to achieve lasting pain relief of refractory low back pain. METHODS: From December 2005 to September 2008, nine patients were operated by bilateral section of rami communicantes for a refractory low back pain. As a diagnostic and predictive test, all patients had, before surgery, a local anaesthetic infiltration of the sympathetic trunk at L2 performed with computed tomography guidance. Surgery is indicated if the tests lead to a reduction in pain of at least 50 %. The procedure, using a retroperitoneal laparoscopic approach, consisted to identify the sympathetic trunk and to section all lumbar rami communicantes from L1 to L2. RESULTS: No intraoperative complications were observed. The mean postoperative follow-up was 29 ± 15 months. At the last follow-up, only 22 % (2/9) patients had an improvement of their low back pain with this surgery but with a minimal effect (30 and 50 % reduction of pain). An improvement of quality of life was observed in 33 % (3/9) of cases. Due to persistent pain, four patients had a spinal cord stimulation after this surgery. CONCLUSIONS: Section the pain pathways carried by sympathetic lumbar rami communicantes for refractory low back pain improved 22 % of patients at the last follow-up of 29 months.

Functional results after tape removal for chronic pelvic pain following tension-free vaginal tape or transobturator tape.

PURPOSE: The incidence of pelvic pain after placement of a suburethral sling for incontinence ranges between 0% and 30%. The management of this chronic pain after suburethral sling placement is complex and to our knowledge no consensus has been reached. We evaluated the functional results after removal of the suburethral tape responsible for chronic pelvic pain. MATERIALS AND METHODS: From November 2004 to August 2009, 32 patients undergoing removal of suburethral tape causing chronic pelvic and perineal pain at our department were prospectively followed. Patients were divided according to the type of suburethral sling into the transobturator tape group (15 patients) and the tension-free vaginal (retropubic) tape group (17 patients). In the TVT group tape removal was performed using transperitoneal laparoscopy in every patient. In the TOT group tape removal was performed via a transvaginal approach possibly associated with a unilateral or bilateral incision in the proximal part of the thigh. Pain was evaluated by a visual analogue scale from 0-no pain to 10-maximal pain. RESULTS: The surgical exploration of suburethral tape responsible for chronic, treatment refractory pelvic pain revealed in most cases an abnormal tape position or excessive tape traction. In the overall population tape removal provided improvement of pain (at least 50% improvement of the visual analogue scale score) in 68% with a mean followup of 10 months. Mean visual analogue scale score was 7.3 +/- 1.5 before surgery and 3.4 +/- 3 after surgery. However, recurrence of incontinence was observed in 22% of cases. No significant difference was demonstrated in terms of functional results according to the type of tape insertion. CONCLUSIONS: The surgical removal of suburethral tape improved pain in 68% of patients but with a risk of recurrence of urinary incontinence in 22%.

Treatment of obturator neuralgia with laparoscopic neurolysis.

PURPOSE: Obturator neuralgia is a cause of pelvic and perineal pain that is rarely suggested, probably because it is poorly understood. We report the results of a pilot study of laparoscopic treatment for obturator neuralgia. MATERIALS AND METHODS: Seven patients (8 nerves) with obturator neuralgia were treated at our department. The etiology was idiopathic in 3 cases and iatrogenic following inguinal hernia surgery in 3 and TVT(R) repair in 2. The diagnosis was based on allodynic pain of the anterior and internal surface of the thigh, which was associated with limping with a sidestepping gait. It was confirmed by an anesthetic block under computerized tomography monitoring using a posterior approach. RESULTS: Treatment consisted of transperitoneal laparoscopic neurolysis with dissection of the nerve and section of the scarring fibrosis or prosthetic mesh in contact with it. In idiopathic cases nerve release was performed by sectioning the internal obturator muscle and the obturator membrane, causing compression and making it possible to widen the obturator foramen. At a mean followup of 16 months the rate of an at least 50% improvement in pain was 87.5% (7 of 8 cases), including complete disappearance of pain in 50% (4 of 8). CONCLUSIONS: Minimally invasive treatment with laparoscopic truncular release of obturator neuralgia yielded encouraging and good results.

Obturator nerve entrapment: diagnosis and laparoscopic treatment: technical case report.

OBJECTIVE: Obturator neuralgia consists of pain radiating from the obturator nerve territory to the inner thigh. METHODS: We report a case of idiopathic obturator neuralgia resulting from compression of the obturator nerve in the obturator canal, causing a case of nerve entrapment syndrome. The pain was characterized by its localization in the inguinal region and anterointernal side of the thigh, going down to the internal side of the knee. It was worse when standing or in a monopodal stance. Walking caused pain and a limp. RESULTS: The diagnosis was confirmed by an analgesic block. The analgesic was infiltrated using a posterior approach and computer-assisted tomography, allowing the quality and specificity of the infiltration to be judged. CONCLUSION: We describe, for the first time, a treatment of obturator neuralgia by a minimally invasive laparoscopic approach. This involved an obturator nerve neurolysis and section of the internal obturator muscle and the obturator membrane.

Intravesical glucidic capsaicin versus glucidic solvent in neurogenic detrusor overactivity: a double blind controlled randomized study.

AIMS: Many studies report the use of alcoholic capsaicin instillation to treat neurogenic detrusor overactivity (NDO) in spinal cord injured (SCI) and multiple sclerosis (MS) patients. However, poor tolerability due to the irritative effect of the ethanol solvent limits its use. Our study aimed to evaluate the efficacy and tolerability of a new formulation of capsaicin in a glucidic solution in a multicenter clinical trial. MATERIALS AND METHODS: Thirty-three patients (26MS/7SCI) suffering from urinary incontinence due to refractory NDO were prospectively enrolled in a double-blind placebo controlled study and randomized to capsaicin group (CG, N = 17) or solvent group (SG, N = 16). They respectively received an intravesical instillation of 100 ml capsaicin diluted in glucidic solvent (CG) or glucidic solvent alone (SG). Efficacy (voiding chart, maximum cystometric capacity (MCC)) and tolerability were evaluated on days 0 (D0), 30 and 90. RESULTS: On D0, groups were homogeneous. On D30, significant improvement of overactive bladder syndrome and an increase in MCC were shown in CG, whereas there were no improvement in SG. No significant improvement was shown on D90 in both groups. There were no significant differences between groups regarding prevalence, duration, or intensity of side effects, except for short duration pubic pain during instillation more often reported in CG (58.8%) than in SG (12.5%) (P < 0.01). CONCLUSION: This placebo controlled study using glucidic capsaicin confirms its short-term efficacy in NDO patients. Global tolerance of glucidic capsaicin appeared satisfactory. Long-term efficacy and tolerance of repeated glucidic capsaicin instillations need to be evaluated.

Decompression and transposition of the pudendal nerve in pudendal neuralgia: a randomized controlled trial and long-term evaluation.

BACKGROUND: We assess that pudendal neuralgia is a tunnel syndrome due to a ligamentous entrapment of the pudendal nerve and have treated 400 patients surgically since 1987. We have had no major complication. We conducted a randomized controlled trial to evaluate our procedure. METHODS: A sequential, randomized controlled trial to compare decompression of the pudendal nerve with non-surgical treatment. Patients aged 18-70, had chronic, uni/bilateral perineal pain, positive temporary response to blocks at the ischial spine and in Alcock's canal. They were randomly assigned to surgery (n=16) and control (n=16) groups. Primary end point was improvement at 3 months following surgery or assignment to the non-surgery group. Secondary end points were improvement at 12 months and at 4 years following surgical intervention. RESULTS: A significantly higher proportion of the surgery group was improved at 3 months. On intention-to-treat analysis 50% of the surgery group reported improvement in pain at 3 months versus 6.2% of the non-surgery group (p=.0155); in the analysis by treatment protocol the figures were 57.1% versus 6.7% (p=.0052). At 12 months, 71.4% of the surgery group compared with 13.3% of the non-surgery group were improved, analyzing by treatment protocol (p=.0025). Only those randomized to surgery were evaluated at 4 years: 8 remained improved at 4 years. No complications were encountered. CONCLUSIONS: In this study we demonstrate that decompression of the pudendal nerve is an effective and safe treatment for cases of chronic pudendal neuralgia that have been unresponsive to analgesia and nerve blocks. Following surgery, other medical interventions may be necessary.

[The catheterized bladder]. / La vessie sondée.

Whatever the cause is, the retention of urine needs a bladder drainage whose mode must not be considered as an evidence. Otherwise, the immediate easiness is likely to be the only criterion of choice. The indwelling catheterization is thus overused, whereas its complications (infectious, cancerous, patient comfort...), which are particularly frequent, should make it be perceived secondarily difficult to manage. Its alternatives, particularly clean intermittent self-catherization and suprapubic catheter, have to be first and systematically discusseed, as well as the relevance of the bladder catherization itself.