Efficacy of ganglion impar block combined with pudendal nerve pulsed radiofrequency for pudendal neuralgia management-a randomized clinical trial.

BACKGROUND: Pudendal neuralgia is a chronic and debilitating condition. Its prevalence ranges from 5 to 26%. Currently, therapeutic approaches to treat pudendal neuralgia include patient education, medication management, psychological and physical therapy, and procedural interventions, such as nerve block, trigger point injections, and surgery. Drug therapy has a limited effect on pain relief. A pudendal nerve block may cause a significant decrease in pain scores for a short time; however, its efficacy significantly decreases over time. In contrast, pudendal nerve pulsed radiofrequency can provide pain relief for 3 months, and ganglion impar block has been widely used for treating chronic perineal pain and chronic coccygodynia. This study aimed to determine the efficacy and safety of monotherapy (pudendal nerve pulsed radiofrequency) and combination therapy (pudendal nerve pulsed radiofrequency plus ganglion impar block) in patients with pudendal neuralgia. METHODS: This randomized, controlled clinical trial will include 84 patients with pudendal neuralgia who failed to respond to drug or physical therapy. Patients will be randomly assigned into one of the two groups: mono or combined treatment groups. The primary outcome will be a change in pain intensity measured using the visual analog scale. The secondary outcomes will include a Self-Rating Anxiety Scale score, Self-Rating Depression Scale score, the use of oral analgesics, the Medical Outcomes Study Health Survey Short Form-36 Item score, and the occurrence of adverse effects. The study results will be analyzed using intention-to-treat and per-protocol analyses. Primary and secondary outcomes will be evaluated between the mono and combined treatment groups. Subgroup analyses will be conducted based on the initial ailment, age, and baseline pain intensity. The safety of the treatment will be assessed by monitoring adverse events, which will be compared between the two groups. DISCUSSION: This study protocol describes a randomized, controlled clinical trial to determine the efficacy and safety of mono and combination therapies in patients with pudendal neuralgia. The study results will provide valuable information on the potential benefits of this combination therapy and contribute to the development of more effective and safer treatments for patients with pudendal neuralgia. TRIAL REGISTRATION: Chinese Clinical Trial Registry (ChiCTR2200061800).

Pudendal nerve blockade for persistent genital arousal disorder (PGAD): A clinical review and case report.

BACKGROUND: Persistent genital arousal disorder (PGAD) is a condition characterized by unwanted and potentially painful genital sensations or spontaneous orgasms without stimulation. We present a case of a 55-year-old woman with refractory genital arousal disorder that was treated with serial pudendal nerve blocks. CASE: RW is a 55-year-old woman with chronic pelvic pain, pudendal neuralgia, MDD, SI, GAD, CRPS, and persistent genital arousal disorder for 11 years. Her PGAD was refractory to conservative management, physical therapy, and bilateral clitoral artery embolization. We performed bilateral pudendal nerve blocks with Kenalog and Bupivacaine, which provided almost complete relief for 2-3 months. We performed a bilateral pudendal nerve radiofrequency ablation; however, there was minimal benefit. RW continues to have significant relief with serial pudendal nerve blocks. SUMMARY AND CONCLUSION: Persistent genital arousal disorder is often refractory to medication and physical therapy requiring significant intervention such as entrapment surgery or artery embolization. Our case demonstrates pudendal nerve blocks as a potential treatment modality with minimal side effects.

[Efficacy and safety of different nerve block methods for the treatment of pudendal neuralgia].

Objective: To identify efficacy and safety of pudendal nerve block in tubing through the third posterior sacral foramen for the treatment of pudendal neuralgia (PN). Methods: A retrospective study with 222 PN patients was conducted in the Department of Pain Management of Beijing Tsinghua Changgung Hospital from January 2020 to April 2023. These patients were divided into two groups based on their treatment methods: pudendal nerve block in tubing through the third posterior sacral foramen (observation group, n=101) and ultrasound-guided pudendal nerve block (control group, n=121). Primary outcome measure was the 90-day postoperative pain relief rate. Secondary outcome measures included visual analog scale (VAS) at 1, 7, 14, 30 and 90 d after surgery, the incidence of tramadol uses after surgery, postoperative self-rating anxiety scale (SAS) scores and the incidence of adverse events. Factors that influenced pain relief within 90 days after surgery were analyzed by using binary logistic regression analysis. Results: Observation group included 34 males and 67 females, aged (49.8±16.0) years old. Control group included 38 males and 83 females, aged (43.7±14.0) years old. The 90-day postoperative pain relief rate of the observation group patients was 38.6% (39/101), which was higher than the 24.0% (29/121) of the control group patients (P=0.018). Both the observation group and the control group showed an interaction effect of time and group after treatment for VAS scores (both P<0.05). In intra-group comparison, the VAS scores at 1, 7, 14, 30 and 90 d after treatment in both groups were lower than those before treatment (all P<0.05). In inter-group comparison, the differences of the VAS scores were not statistically significant in the observation group compared with those in the control group at 1, 7, 14, 30 and 90 d after surgery (all P>0.05). The SAS score of the observation group at 90 d after surgery was 51.5±6.2, which was lower than the 53.4±5.8 of the control group (P=0.022). There was no statistically significant difference in the incidence of postoperative tramadol uses and adverse events between the two groups (both P>0.05). Pudendal nerve block in tubing through the third posterior sacral foramen was a protective factor for pain postoperative relief in PN patients at 90 d after surgery (OR=1.92, 95%CI: 1.05-3.48, P=0.033). Conclusion: Pudendal nerve block in tubing through the third posterior sacral foramen is a safe and effective minimally invasive treatment. It has a higher postoperative pain relief rate within 90 d after surgery, without increasing the uses of postoperative rescue analgesics and the incidence of adverse events.

YouTube and pudendal neuralgia: Is it a good source of information for patients?

OBJECTIVE: This study aims to identify the shortcomings and quality content of YouTube videos and its effectiveness as a source of patient information on pudendal neuralgia treatment. METHODS: A search was conducted on YouTube using the words "pudendal neuralgia physical therapy," "medications for pudendal neuralgia," "pudendal nerve block," "pudendal neuralgia surgery," and "alternative treatments for pudendal neuralgia." The results were analyzed based on the source, general descriptive statistics, the intended audience, and five content areas. The DISCERN scoring system was used to evaluate the quality of videos. RESULTS: After the search, 73 videos met the inclusion criteria for further analysis. The majority of these videos (61.64%) were intended to target the general population, whereas a smaller percentage were identified as professional (41.10%) or targeted for physicians (35.62%). From the videos included, 10 (13.70%) described treatment options in a balanced and evidence-based manner. The higher DISCERN score positively correlated with the presence of this last content criterion. With a total DISCERN mean score of 35.42, a significant proportion of the videos (41.10%) were rated very poor. The remaining videos were classified as poor (23.29%), fair (19.18%), good (8.22%), and excellent (8.22%). CONCLUSION: The quality of the information included in YouTube videos regarding pudendal neuralgia treatment was considered generally poor. Healthcare providers must recognize the potential influence of this platform on patients' understanding of pudendal neuralgia treatment. There is a need for additional research and randomized studies regarding YouTube content about this condition.

First case-series of robot-assisted pudendal nerve release: technique and outcomes.

OBJECTIVE: Pudendal Nerve Entrapment (PNE) may determine chronic pelvic pain associated with symptoms related to its innervation area. This study aimed to present the technique and report the outcomes of the first series of robot-assisted pudendal nerve release (RPNR). PATIENTS AND METHODS: 32 patients, who were treated with RPNR in our centre between January 2016 and July 2021, were recruited. Following the medial umbilical ligament identification, the space between this ligament and the ipsilateral external iliac pedicle is progressively dissected to identify the obturator nerve. The dissection medial to this nerve identifies the obturator vein and the arcus tendinous of the levator ani, which is cranially inserted into the ischial spine. Following the cold incision of the coccygeous muscle at the level of the spine, the sacrospinous ligament is identified and incised. The pudendal trunk (vessels and nerve) is visualized, freed from the ischial spine and medially transposed. RESULTS: The Median duration of symptoms was 7 (5, 5-9) years. The median operative time was 74 (65-83) minutes. The median length of stay was 1 (1-2) days. There was only a minor complication. At 3 and 6 months after surgery, a statistically significant pain reduction has been encountered. Furthermore, the Pearson correlation coefficient reported a negative relationship between the duration of pain and the improvement in NPRS score, - 0.81 (p = 0.01). CONCLUSIONS: RPNR is a safe and effective approach for the pain resolution caused by PNE. Timely nerve decompression is suggested to enhance outcomes.

Clinical usefulness of quantitative thermal sensory testing in the diagnosis and surgical treatment of women with pudendal neuropathy.

BACKGROUND: The aim of this study, conducted on women with pudendal neuropathy, was to evaluate the usefulness of quantitative thermal sensory testing (QTST) in the diagnosis, surgical management, and prognosis of the disease. METHODS: The study was conducted on 90 women with pudendal neuropathy. QTST in pudendal nerve sensory innervation territory was realized before and more than 24 months after operative pudendoscopy on most patients. Cold and warm thresholds were evaluated together with a search for qualitative anomalies. The diagnostic value of QTST was assessed by comparing baseline data with normative values previously derived from 41 presumably healthy women. The effect of operative pudendoscopy on thermal sensitivity was tested by comparing preoperative and postoperative measurements. Assessment of the long-term prognostic value of QTST was based on "surgical success" defined as a VAS pain level less than 4 at least 2 years after surgery. RESULTS: The existence of qualitative anomalies, like anesthesia, allodynia, dysesthesia, radiation, and dyslocalization, was clearly indicative of pudendal neuropathy. The presence of after sensation and "out of limit" values of skin temperature and cold detection threshold were also helpful for diagnosing the disease. Surgery reduced qualitative anomalies but had no positive effect on QTST thresholds. QTST measurements had no real prognostic value but other factors like constipation and abnormal perineal descent were predictive of surgical success. CONCLUSION: For women with pudendal neuropathy, QTST can be considered a useful, non-invasive tool in the diagnosis, and management of the disease, but it cannot predict satisfactorily long-term outcome of operative pudendoscopy.

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.

Retroperitoneal Causes of Genitourinary Pain Syndromes: Systematic Approach to Evaluation and Management.

INTRODUCTION: Women with pelvic pain commonly report pain in their ovaries, vagina, uterus, or bladder. These symptoms may be caused by visceral genitourinary pain syndromes but also may be caused by musculoskeletal disorders of the abdomen and pelvis. Understanding neuroanatomical and musculoskeletal factors that may contribute to genitourinary pain is important for evaluation and management. OBJECTIVES: This review aims to (i) highlight the importance of clinical knowledge of pelvic neuroanatomy and sensory dermatomal distribution of the lower abdomen, pelvis, and lower extremities, exemplified in a clinical case; (ii) review common neuropathic and musculoskeletal causes of acute and chronic pelvic pain that may be challenging to diagnose and manage; and (iii) discuss female genitourinary pain syndromes with a focus on retroperitoneal causes and treatment options. METHODS: A comprehensive review of the literature was performed by searching the PubMed, Ovid Embase, MEDLINE, and Scopus databases using the keywords "chronic pelvic pain," "neuropathy," "neuropathic pain," "retroperitoneal schwannoma," "pudendal neuralgia," and "entrapment syndromes." RESULTS: Retroperitoneal causes of genitourinary pain syndromes have substantial overlap with common conditions treated in a primary care setting. Thus, a comprehensive and systematic history and physical examination, with focused attention to the pelvic neuroanatomy, is key to establishing the correct diagnosis. In the clinical case, such a comprehensive approach led to the unexpected finding of a large retroperitoneal schwannoma. This case highlights the intricacy of pelvic pain syndromes and the complex nature of their possible overlapping causes, which ultimately affects treatment planning. CONCLUSION: Knowledge of the neuroanatomy and neurodermatomes of the abdomen and pelvis, in addition to understanding pain pathophysiology, is critical when evaluating patients with pelvic pain. Failure to apply proper evaluation and implement proper multidisciplinary management strategies contributes to unnecessary patient distress, decreased quality of life, and increased use of health care services. Khalife T, Hagen AM, Alm JEC. Retroperitoneal Causes of Genitourinary Pain Syndromes: Systematic Approach to Evaluation and Management. Sex Med Rev 2022;10:529-542.

Sacral Nerve Stimulation in Patients With Refractory Pudendal Neuralgia.

BACKGROUND: Pudendal neuralgia (PN) is one of the most common forms of genital pain. Only 42.2% of PN patients respond to the first-line treatment. Novel neuromodulation techniques in the treatment of refractory PN patients are urgently required. OBJECTIVES: The aim of this study was to evaluate the treatment effects and adverse events of sacral nerve stimulation (SNS) for patients with refractory PN. STUDY DESIGN: A prospective nonrandomized study. SETTING: This prospective analysis included 33 patients who received the phase II surgical implantation. METHODS: A total of 55 eligible PN patients were recruited for SNS treatment after informed consent, and 33 of 55 patients with a minimum 50% improvement were candidates for surgical implantation. Visual Analog Scale (VAS) scores, Self-rating Anxiety and Depression Scale, Quality of life score (SF-36), and sleep monitoring indicators before and after surgery were used to assess the effects of SNS on patients with refractory PN. RESULTS: Thirty-three patients were included in the final analysis, involving 24 women and 9 men with a mean age of 49.5 years (26-70 years). There was a favorable decrease in pain severity (VAS scores) from 7.1 ± 1.1 at baseline to 6.1 ± 1.0 on postoperative day 1, and 2.8 ± 0.7 at 1 week, 1.7 ± 0.5 at 1 month, 1.1 ± 0.7 at 6 months, and 1.0 ± 0.6 at 12 months after surgery, respectively (P < 0.05). The mean score of each section of SF-36 after SNS was significantly higher than that at baseline (P < 0.05). Total sleep time and sleep time in each period were significantly prolonged after SNS implantation compared with that before surgery (6 months vs Pre, total: 5.32 ± 1.49 hours vs 3.66 ± 1.19 hours, deep: 2.52 ± 0.63 hours vs 1.36 ± 0.43 hours, light: 1.78 ± 0.42 hours vs 0.99 ± 0.30 hours, rapid eye movement: 1.41 ± 0.29 hours vs 0.89 ± 0.27 hours, P < 0.05). No serious device complications were reported during the follow-up period. LIMITATIONS: Large-scale randomized clinical trials are warranted to evaluate the risk factors for prediction of refractory PN. CONCLUSIONS: These data imply that SNS can have beneficial effects on patients with refractory PN.

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.

Right laparoscopic pudendal release + neurostimulator prosthesis (LION procedure) in pudendal neuralgia.

AIM: Pudendal neuralgia is a highly disabling entity with complex diagnostic and controversial treatment results. Surgical neurolysis has been shown to be the most effective treatment. Sacral root neurostimulation or posterior tibial nerve stimulation are used to rescue patients who either have not responded to surgery or have worsened after an initial improvement. METHODS: Given the excellent visualization of the pudendal nerve during laparoscopic pudendal release, we propose to combine this procedure with neurostimulation, taking advantage of the possibility of in situ placement of the electrode. The abdominal cavity is accessed laparoscopically through four ports, and after identifying and releasing the pudendal nerve a neurostimulation electrode is placed next to the nerve and is connected to a generator located in a subcutaneous pocket. RESULTS: This procedure has been performed in one patient with a satisfactory result. CONCLUSIONS: Laparoscopic pudendal release with neurostimulator prosthesis is an experimental technique that can be promising for the treatment of pudendal neuralgia.

Pudendal Neuromodulation is Feasible and Effective After Pudendal Nerve Entrapment Surgery.

BACKGROUND: Patients with intractable pain in the pudendal nerve distribution may benefit from pudendal neuromodulation; however, some may have previously undergone pudendal nerve entrapment surgery (PNES), potentially altering nerve anatomy and function. AIM: We examined pudendal neuromodulation outcomes in patients with prior PNES. METHODS: Patients with a history of PNES and quadripolar, tined pudendal lead placement for urogenital pain were reviewed. Symptoms and outcomes were collected from existing medical records. OUTCOMES: Patients with pudendal neuromodulation and prior PNES were compared to patients with no prior PNES who had pudendal lead placement. RESULTS: Fifteen patients with a history of 1, 2, or 3 prior PNES (n = 13, 1, and 1, respectively) were evaluated. Most (10; 67%) were female, with bilateral pain (9; 60%), and symptoms of 5-26 years. After trialing the lead, bladder symptoms and pain were improved in 8 of 12 and 9 of 14 patients, respectively, and 80% of patients (12/15) underwent permanent generator implantation. When prior PNES patients were compared to those with no prior PNES (n = 43), gender (67% vs 77% female; P = .50) and age (median 63 vs 58 years; P = .80), were similar; however, BMI differed (mean 24 vs 29; P = .008) and a lower proportion (12/15; 80% vs 42/43; 98%; P = .049) had generator implantation. Importantly, median lead implant time (48 vs 50 minutes; P = .65) did not differ between the 2 groups. CLINICAL IMPLICATIONS: Pudendal neuromodulation has the potential to provide pain relief for a very difficult-to-treat population; furthermore, it does not appear that prior PNES surgery made lead placement significantly more challenging. STRENGTHS & LIMITATIONS: Study strengths include being a tertiary referral center for urogenital pain and having a single surgeon perform all procedures in a regimented way. Limitations include the retrospective study design, small sample size and various approaches to PN CONCLUSION: Chronic pudendal neuromodulation can be a viable option even after prior PNES. Kristen M. Meier, Patrick M. Vecellio, Kim A. Killinger, Judith A. Boura, Kenneth M. Peters. Pudendal Neuromodulation is Feasible and Effective After Pudendal Nerve Entrapment Surgery. J Sex Med 2022;19:995-1001.

Surgical management of pudendal nerve entrapment after sacrospinous ligament fixation.

OBJECTIVE: To analyse the efficacy of sacrospinous ligament (SSL) suture removal on the reduction of pain symptoms in the case of suspected pudendal nerve entrapment after sacrospinous ligament fixation (SSLF). DESIGN: Retrospective cohort study. SETTING: Tertiary referral centre, the Netherlands. POPULATION: A cohort of 21 women having their SSLF sutures removed because of SSLF-related pain symptoms. METHODS: Clinical record review. MAIN OUTCOME MEASURES: The primary outcome was reduction of pain after SSL suture removal. Secondary outcome measures were time interval between suture placement and suture removal, complete suture removal, adverse events and recurrence of pelvic organ prolapse (POP). RESULTS: A total of 21 women underwent SSL suture removal for severe and/or persistent pain, which was confirmed on clinical examination: 95% of the women (20/21) reported pain reduction after suture removal, and 57% reported complete pain relief. The time interval between suture placement and suture removal was at a median of 414 days (range 8-1855 days). Sutures could be completely removed in 86% of cases (18/21). One woman had excessive blood loss (520 ml) without blood transfusion. At 6-8 weeks after surgery, 10% of the women (2/21) had renewed symptomatic POP, stage ≥ 2, for which additional POP surgery was indicated. CONCLUSIONS: When performed by an experienced clinician, SSL suture removal is feasible and efficacious, with low morbidity. In addition, the risk of recurrent POP in the short term appeared to be low. TWEETABLE ABSTRACT: The surgical removal of sacrospinous ligament sutures is safe and efficacious for pain relief, even remote from initial placement.

Is pudendal nerve entrapment a potential cause for weak ejaculation?

Ejaculatory dysfunction is one of the most common complaints of patients with sexual disorders. While it encompasses several ejaculatory disorders, weak ejaculation is seldom described in the literature. Since the pudendal nerve is the main nerve of ejaculation, we aim to hypothesize that pudendal nerve entrapment could be a cause of weak ejaculation, and that pudendal nerve release could contribute to the improvement of the ejaculatory stream. We presented two cases suffering from a weak ejaculatory stream and sensation of incomplete semen emptying, accompanied with clinical features of pudendal nerve entrapment. Both cases improved after pudendal nerve block and then laparoscopic transperitoneal pudendal release, with a sustained amelioration of the ejaculatory stream after 3 weeks of surgery. Pudendal canal entrapment is therefore a potentially curable cause for weak ejaculation.

Pudendal nerve block: a safe, simple and effective approach in surgical proctological patients.

BACKGROUND: Pudendal nerve block (PNB) is commonly used in pudendal neuralgia (PN) and, as anesthesiological technique, in obstetrical and urological procedures. The purpose of this retrospective study was to compare the efficacy of PNB with other anesthesiolocal techniques in proctological surgery. METHODS: A total of 362 patients were seen from a 22-month-time interval. Surgical indication was placed after a conservative therapy. Seventy-eight patients underwent surgery: 42 with spinal anesthesia with PNB and 36 with PNB alone according to their anatomical characteristics. All the patients underwent PNB in lithotomy position and with a perirectal approach. The success rate of PNB was evaluated in postoperative pain control with the VAS score, after the first and the second evacuation. The follow-up also included a third check on the seventh day after surgery. RESULTS: In postoperative period, the mean VAS score found after the first evacuation in patients undergoing PNB was 2.66, after the second evacuation was 1.55, while the VAS score on the seventh day was 0.38. The mean VAS score in the group who underwent spinal anesthesia and PNB were respectively 3.71 and 1.80 after the first and second evacuation. The VAS score calculated on the seventh day was 0.50. There were no statistically significant differences in the VAS score between the 2 groups (P>0.05). CONCLUSIONS: PNB may be a valid alternative to spinal anesthesia in proctological patients. PNB has proven to be both safe and effective technique.

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.

Retroperitoneal Causes of Genitourinary Pain Syndromes: Systematic Approach to Evaluation and Management.

INTRODUCTION: Women with pelvic pain commonly report pain in their ovaries, vagina, uterus, or bladder. These symptoms may be caused by visceral genitourinary pain syndromes but also may be caused by musculoskeletal disorders of the abdomen and pelvis. Understanding neuroanatomical and musculoskeletal factors that may contribute to genitourinary pain is important for evaluation and management. OBJECTIVES: This review aims to (i) highlight the importance of clinical knowledge of pelvic neuroanatomy and sensory dermatomal distribution of the lower abdomen, pelvis, and lower extremities, exemplified in a clinical case; (ii) review common neuropathic and musculoskeletal causes of acute and chronic pelvic pain that may be challenging to diagnose and manage; and (iii) discuss female genitourinary pain syndromes with a focus on retroperitoneal causes and treatment options. METHODS: A comprehensive review of the literature was performed by searching the PubMed, Ovid Embase, MEDLINE, and Scopus databases using the keywords "chronic pelvic pain," "neuropathy," "neuropathic pain," "retroperitoneal schwannoma," "pudendal neuralgia," and "entrapment syndromes." RESULTS: Retroperitoneal causes of genitourinary pain syndromes have substantial overlap with common conditions treated in a primary care setting. Thus, a comprehensive and systematic history and physical examination, with focused attention to the pelvic neuroanatomy, is key to establishing the correct diagnosis. In the clinical case, such a comprehensive approach led to the unexpected finding of a large retroperitoneal schwannoma. This case highlights the intricacy of pelvic pain syndromes and the complex nature of their possible overlapping causes, which ultimately affects treatment planning. CONCLUSION: Knowledge of the neuroanatomy and neurodermatomes of the abdomen and pelvis, in addition to understanding pain pathophysiology, is critical when evaluating patients with pelvic pain. Failure to apply proper evaluation and implement proper multidisciplinary management strategies contributes to unnecessary patient distress, decreased quality of life, and increased use of health care services.

Advances in the therapeutic approach of pudendal neuralgia: a systematic review.

CONTEXT: Although pudendal neuralgia (PN) has received growing interest over the last few years, diagnosis remains difficult, and many different therapeutic approaches can be considered. OBJECTIVES: This article aims to provide an overview of the possible treatments of PN and investigate their efficacies. METHODS: Utilizing PubMed and ScienceDirect databases, a systematic review was carried out and allowed identification of studies involving patients with PN, as defined by Nantes criteria, and their associated treatments. Relevant data were manually reported. RESULTS: Twenty-eight articles were selected, totaling 1,013 patients (mean age, 49 years) and six different types of interventions. Clinical outcomes, most frequently quantified utilizing the Visual Analog Scale (VAS), vary greatly with both the therapy and time after intervention (from 100 to <10%). However, neither peri nor postoperative serious complications (grade > II of Clavien-Dindo classification) are reported. Although surgery seems to provide a higher proportion of long-term benefits, identifying the most efficient therapeutic approach is made impossible by the multitude of outcome measurements and follow-up frequencies. It should also be noted that literature is sparse regarding randomized controlled trials with long-term follow-up. CONCLUSIONS: Although there are a number of modalities utilized for the treatment of PN, there are no current recommendations based on treatment efficacies. This seems to be largely in part caused by the lack of standardization in outcome quantification. Future research in this field should focus on prospective cohort studies with high levels of evidence, aimed at assessing the long-term, if not permanent, benefits of available therapies.

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.