Sperm cryopreservation and assisted reproductive technology outcome in patients with spinal cord injury.

This study aimed to describe spinal cord injured patients' semen characteristics before and after cryopreservation, and assisted reproductive technology cycles outcome compared to the infertile population. Data about sperm analysis and assisted reproductive technology (ART) cycles outcomes for 78 men with spinal cord injury referred for sperm cryopreservation between 1998 and 2013 were retrospectively analysed and compared with a reference group consisting of every Intra Cytoplasmic Sperm Injection (ICSI) cycle performed in our in vitro fertilization unit over the 2009-2014 period. Semen was collected by penile vibratory stimulation (PVS), electroejaculation or via testis biopsies. Fresh and frozen semen parameters and ART outcomes with frozen-thawed sperm were measured. Patients were divided into three groups according to the sperm retrieval methods: 37 electroejaculations, 37 PVSs and four surgical sperm retrievals. Low ejaculate volume was observed in 33% of the patients, and oligozoospermia in 37% of the patients. Specimens from 77 of the patients contained motile sperm and were therefore frozen for future use. There was no statistical difference for any of the fresh semen parameters between all groups. Twenty of them underwent ICSI leading to five live births, while four underwent intrauterine insemination. ART with frozen-thawed spermatozoa can provide men with SCI with comparable results as in the infertile population.

Adding corticosteroids to the pudendal nerve block for pudendal neuralgia: a randomised, double-blind, controlled trial.

OBJECTIVE: To compare the effect of corticosteroids combined with local anaesthetic versus local anaesthetic alone during infiltrations of the pudendal nerve for pudendal nerve entrapment. DESIGN: Randomised, double-blind, controlled trial. SETTING: Multicentre study. POPULATION: 201 patients were included in the study, with a subgroup of 122 women. METHODS: CT-guided pudendal nerve infiltrations were performed in the sacrospinous ligament and Alcock's canal. There were three study arms: patients in Arm A (n = 68) had local anaesthetic alone, those in Arm B (n = 66) had local anaesthetic plus corticosteroid and those in Arm C (n = 67) local anaesthetic plus corticosteroid with a large volume of normal saline. MAIN OUTCOME MEASURES: The primary end-point was the pain intensity score at 3 months. Patients were regarded as responders (at least a 30-point improvement on a 100-point visual analogue scale of mean maximum pain over a 2-week period) or nonresponders. RESULTS: Three months' postinfiltration, 11.8% of patients in the local anaesthetic only arm (Arm A) were responders versus 14.3% in the local anaesthetic plus corticosteroid arms (Arms B and C). This difference was not statistically significant (P = 0.62). No statistically significant difference was observed in the female subgroup between Arm A and Arms B and C (P = 0.09). No significant difference was detected for the various pain assessment procedures, functional criteria or quality-of-life criteria. CONCLUSIONS: Corticosteroids provide no additional therapeutic benefits compared with local anaesthetic and should therefore no longer be used. TWEETABLE ABSTRACT: Steroid infiltrations do not improve the results of local anaesthetic infiltrations in pudendal neuralgia.

[Pelvi-perineal chronic pain, urgent demands of care and decision-making]. / Douleurs pelvipérinéales chroniques, demandes urgentes de soins et prise de décision.

OBJECTIVE: Some patients suffering from pelvi-perineal chronic pain express urgent, even vital, demands of care. The objective was to compare the profile and the psychological functioning of the patients, who have shown an imperious demand of care, in that of the patients who do not have an imperious demand of care. MATERIAL AND METHOD: From the medical consultations for chronic pelviperineal pain, we realized a comparative study including 26 patients (experimental group) expressing an urgent demand of care (i.e., patients who, during the last 3months, called an emergency service concerning the pains for which they consult in the service) and 28 patients (control group) without an urgent demand of care (i.e., patient who, during the last 3months, did not call an emergency service concerning the pains for which they consult in the service). All the patients were tested through a cognitive task of decision-making (Iowa Gambling Task) and through explicit measures of pain and its main psychological associated factors (anxiety, depression, impulsivity an catastrophism). RESULTS: In the first place, the patients from the experimental group possess decision-making abilities equivalent to the patients of the control group; however, both groups of patients show, in the beginning of the test, a deficit in the decision-making (F(4.208)=3.4116; P=.009). Secondly, the measures to questionnaires reveal that the patients of the control group have less severe scores in the scales of depression (t(52)=-2.068; P<04), catastrophism (amplification : t(52)=-3.069; P<0035; powerlessness: t(52)=-2.866, P<.006) and impulsivity (positive urgency: t(52)=-2.246, P<029; lack of premeditation: t(52)=-2.175, P<035) than the patients of the experimental group. CONCLUSION: The use of explicit measures (questionnaire) and implicit measures (experimental task) allowed to objectify more precisely the differences between the chronic pain patients in urgent demand of care and the other chronic pain patients. This psychological specificity obliges us to approach differently the caring of these patients in particular by proposing adapted cognitivo-behavioral techniques. LEVEL OF EVIDENCE: 3.

[Interest of infiltration of Impar node in rebel vulvodynia: About a series of 8 cases]. / Intérêt de l'infiltration du ganglion Impar dans les vulvodynies rebelles : à propos d'une série de 8 cas.

INTRODUCTION: Vulvodynia is a common and debilitating disease, for which treatments are often of limits efficacy. As the Impar node receives nociceptive afferents from pelvis and perineum, it is a potential therapeutic target to treat pain in this region. The objective of the study was to evaluate the relevance of ropivacaine Impar node infiltration in patients suffering from rebel vulvodyny. METHODS: This was a retrospective, single-center study. The Impar node infiltrations were performed by a single operator in eight patients suffering from rebel vulvodynia. Ropivacaine and iopamidol were administered in prone position with a lateral approach under scanner. The anaesthetic diagnostic block of the Impar node was positive in all eight patients included in the study. Thereafter these patients benefited of 2 additional therapeutic infiltrations. Subsequently, an infiltration of the node with 100UI of botulinum toxin was performed in two patients with a bilateral approach under scanner. The analgesic efficacy was evaluated by a Visual Analogic Scale (VAS) before, immediately after, and at day 15 following the infiltration. A subjective evaluation of pain comprising the percentage of overall improvement and duration of analgesic efficacy was performed after the third infiltration. RESULTS: Comparison of the VAS before and immediately after the Impar block showed in the first anesthetic block a significant decrease in pain median VAS from 51/100 to 16/100 (P=0.01). Similarly, for the second block, VAS decreased from 52.5/100 to 15/100 (P=0.02). The maximal pain reported on Day 15, was significantly lower after the third infiltration than that after the first (P=0.03). Five patients reported an overall improvement in their quality of life of over 50%, which lasted an average of six weeks. A long lasting effectiveness was obtained in the two patients who benefited of the botulinum toxin. CONCLUSION: The infiltration of Impar node is an interesting technique for patients suffering of rebel vulvodynia. LEVEL OF EVIDENCE: 4.

[French translation of "An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for female pelvic floor dysfunction" published in Int Urogynecol J 2010;21(1):5-26]. / Traduction française de la terminologie commune International Urogynecological Association (IUGA)/International Continence Society (ICS) sur les troubles de la statique pelvienne chez la femme initialement publiée dans Int Urogynecol J 2010;21(1):5-26.

INTRODUCTION AND HYPOTHESIS: Given its increasing complexity, the terminology for female pelvic floor disorders needs to be updated in addition to existing terminology of the lower urinary tract. To do this, it seems preferable to adopt a female-specific approach and build on a consensus based on clinical practice. METHODOLOGY: This paper summarizes the work of the standardization and terminology committees of two international scientific societies, namely the International Urogynecological Association (IUGA) and the International Continence Society (ICS). These committees were assisted by many external expert referees. A ranking into relevant major clinical categories and sub-categories was developed in order to allocate an alphanumeric code to each definition. An extensive process of 15 internal and external reviews was set up to study each definition in detail, with decisions taken collectively (consensus). RESULTS: Terminology was developed for female pelvic floor disorders, bringing together more than 250 definitions. It is clinically based and the six most common diagnoses are defined. The emphasis was placed on clarity and user-friendliness to make this terminology accessible to practitioners and trainees in all the specialties involved in female pelvic floor disorders. Imaging investigations (ultrasound, radiology, MRI) exclusively for women have been added to the text, relevant figures have also been included to complete the text and help clarify the meaning. Regular reviews are planned and are also required to keep the document up-to-date and as widely acceptable as possible. CONCLUSIONS: The work conducted led to the development of a consensual terminology of female pelvic floor disorders. This document has been designed to provide substantial assistance in clinical practice and research. LEVEL OF EVIDENCE: 4.

[Painful ejaculation]. / L'éjaculation douloureuse.

OBJECTIVE: To clarify definition, epidemiology, diagnosis, evaluation, etiologies and treatment of painful ejaculation (PE). MATERIAL AND METHODS: Review of the literature performed by searching the Medline database using keywords ejaculation, orgasm, pain, pelvic pain, sexual behavior. RESULTS: PE is a pelviperineal pain caused by ejaculation or orgasm. Its prevalence rate is between 1 and 4% amongst the general population. Mainly located in the penis, pain usually lasts less than 5 minutes. Assessment is clinical and there is no level of evidence about the strategy of complementary investigations. Benign prostatic hyperplasia, chronic pelvic pain syndrome, radical prostatectomy, prostate brachytherapy and some antidepressant medications are the best estimated etiologies found in the literature. A link between urogenital infections and PE is likely but not clearly established. Alpha-blockers had good therapeutic results in few low level of evidence studies. CONCLUSION: The assessment of PE is not clearly defined. Some etiologies are known but PE may be a functionnal pain. Only high level of evidence studies would validate the use of the alpha-blockers as an efficient therapeutic option.

Anatomical basis of digital rectal examination.

PURPOSE: Rectal examination is difficult to carry out by students because of their lack of knowledge and fear. It is therefore necessary to search for methods in order to facilitate its practice. This work mainly focuses on the palpation of the posterior lateral area of the rectum. METHODS: This work bases itself on the study of the average length of indexes and on the anatomical study of the dissection and prints of two pelvises. In the lithotomy position, we can identify three successive levels of exploration of the posterior and lateral area of the rectum. These three levels are defined by the extremity of the index, and the distal and proximal interphalangeal articulations placed successively on the tip of the coccyx. A 180° rotation of the hand enables at each level to identify the parietal structures that the pad of the index comes across, but excludes the palpation of genital organs and rectum. RESULTS: The first level corresponds to the higher part of the anal canal, the ischioanal fossa and the ischium. The second level corresponds to the levator ani muscle, the ischioanal fossa and the pudendal canal. The third level corresponds to the sacrospinous ligament, the ischiatic spine and the internal obturator muscle. CONCLUSIONS: In spite of the significant differences between the lengths of the indexes, the use of these landmarks will facilitate the identification of parietal anatomical structures. The internal organs' palpation will depend on the patient's position, his efforts in pushing, the length of the index, and the way the examiner presses on the perineum.

[Cluneal inferior neuralgia by conflict around the ischium: Identification of a clinical entity from a series of anesthetic blocks in 72 patients]. / La névralgie clunéale inférieure par conflit au niveau de l'ischion : identification d'une entité clinique à partir d'une série de blocs anesthésiques chez 72 patients.

INTRODUCTION: Some patients have atypical perineal neuropathic pain that differs from a pudendal neuralgia. The purpose of this study was to define a new clinical entity of such pain and to evaluate the therapeutic benefit of corticosteroid infiltration. MATERIAL AND METHODS: Retrospective study of 72 patients presenting with atypical perineal pain. A nerve block was performed using added steroid anesthetic in cluneal inferior nerve, at the endo-ischial area. Pain assessment was recorded 8 days and 10 minutes before the injection and 5 minutes and 3 weeks after the procedure. RESULTS: The population included 40 (55%) women, mean age 55. Forty-nine (68%) patients presented with a positive block test. These patients were characterized by ischio-perineal neuropathic pain, respecting the penis or clitoris, worse sitting (98%), especially on hard seats, do not wake up at night, and not accompanied by superficial hypoesthesia. A decrease in VAS scores (>30%) at 23 weeks follow-up following the addition of corticosteroids during infiltration was observed in only 29 (40%) patients. CONCLUSION: The current series described the population characteristics of cluneal inferior neuralgia by ischial conflict.

[Vulvodynia and chronic pelvic and perineal pain]. / Vulvodynies et douleur pelvipérinéales chroniques.

OBJECTIVE: To define vulvodynia and to describe the main approaches to treatment. MATERIAL AND METHODS: Review of the literature concerning vulvodynia. RESULTS: Vulvodynia is defined as chronic vulvar discomfort, usually with a burning nature, with no relevant clinical lesions and no clinically identifiable neurological lesion. Localized provoked vulvodynia essentially affects young women and is responsible for major sexual and psychological repercussions. Treatment consists of local anaesthetics, drugs used to treat neuropathic pain, physiotherapy and psychotherapy. Vestibulectomy is only very rarely indicated. CONCLUSION: Many unknowns persist especially concerning the aetiology of vulvodynia. Evaluation of symptoms and treatment have not been clearly defined. However, symptomatic management provide satisfactory long-term results.

[Chronic pelvic pain in urology: a nationwide questionnaire survey among French urologists]. / Douleurs pelvipérinéales chroniques en urologie: enquête auprès des urologues français.

OBJECTIVE: To know the opinion of French urologists concerning the importance of pelvic and perineal pain syndromes in their clinical activity, their management, self-admitted knowledge and training needs concerning this situation. MATERIAL AND METHODS: Eight hundred and seventy-eight urologists exercising in France, all French Urology Association (AFU) members, have been asked to fill in an online questionnaire concerning their daily management of chronic pelvic and perineal pain syndromes. RESULTS: Three hundred and fifty-two urologists answered (response rate 40%). For about 20%, chronic pelvic and perineal pain syndromes took up more than 5% of consult activity. More than half took care of between 20 and 100 new cases of chronic pelvic and perineal pain every year. More than two thirds deemed their knowledge concerning chronic pelvic and perineal pain fair to insufficient. Three quarters of urologists would like to benefit from an opinion from another specialist for more than one out of four patients. More than 56% deemed that the organization of their daily consult activity was inadequate for the management of this type of patient. Most of them deemed useful to develop additional specific training programs. CONCLUSION: This survey shows that pelvic and perineal pain syndromes are frequent in daily urological consult activity, despite the fact that urologists feel they lack in training and organization to manage properly these diseases.

[Evaluation of chronic pelvic and perineal pain]. / Évaluation des douleurs pelvipérinéales chroniques.

OBJECTIVE: To describe the tools allowing evaluation of chronic pelvic and perineal pain and to define their indications. MATERIAL AND METHODS: A review of the literature was performed by searching the Medline database (National Library of Medicine). Search terms were either Medical subject heading (MeSH) keywords (pelvic pain, pain measurement, prostatitis, quality of life) or terms derived from the title or abstract. Search terms were used alone or in combinations by using the "AND" operator. The literature search was conducted from 1990 to the present time. RESULTS: Various rating scales and questionnaires constitute useful tools for clinical evaluation of the patient's chronic pain. They cannot replace clinical interview and cannot be used to establish a diagnosis. The main clinical assessment tools include severity scales, body diagrams, descriptive assessment (sensory and affective), evaluation of the impact on sleep, activities of daily living, quality of life and behaviour and assessment of mood and anxiety. In addition to these general tools, specific questionnaire have been developed in the fields of interstitial cystitis/painful bladder syndrome and chronic prostatitis/chronic pelvic pain syndrome. These specific questionnaires are designed for evaluation of the severity of symptoms, assessment of the disability related to the symptoms and the impact on quality of life, and follow-up of the course of symptoms and the response to treatment. CONCLUSION: Rapid and easy to use tools are essential in routine clinical practice. The recommended assessment tools are VAS (visual analogue scale) or numerical severity scales, body diagrams and brief questionnaires such as the Questionnaire sur la Douleur de Saint-Antoine (QDSA) (Saint-Antoine pain questionnaire) or Questionnaire Concis sur les Douleurs (QCD) (validated French translation of the Brief Pain Inventory).

[Chronic pelvic pain: epidemiology and economic impact]. / Épidémiologie et aspects économiques des douleurs pelvipérinéales chroniques.

OBJECTIVE: To combine epidemiological and health economics data concerning urological chronic pelvic pain syndromes. MATERIAL: Review of articles concerning this topic in the Medline (PubMed) database, chosen according to their scientific relevance. RESULTS: Prevalences are about 10,000/100,000 for chronic pelvic pain syndrome/chronic prostatis, 239 to 306/100,000 for bladder pain syndrome/interstitial cystitis, 15,000 to 20,000/100,000 for post-vasectomy testis and epididymis pain, 14,000/100,000 concerning deep female dyspareunia, 1000 to 9000/100,000 for male ejaculation or orgasma-related pain, 15,000 to 21,000/100,000 for female chronic pelvic pain, of which one third is related to endometriosis. Little has been published about the frequency of other chronic pelvic and perineal pain syndromes. The financial impact is comparable to other more frequent chronic diseases, with costs definitely above what the prevalences would have led to believe. CONCLUSION: The frequency of pelvic disease association, their predisposing factors, common environments and comordities suggest a possible common origin. This epidemiological data highlights the benefit of a multidisciplinary approach of chronic pelvic and perineal pain. This could lead to a better understanding of involved mechanisms, and ultimately treatment options.

[Definitions, classifications and terminology of chronic pelvic and perineal pain]. / Définitions, classifications et lexique des douleurs pelvipérinéales chroniques.

OBJECTIVE: To review the definitions and classifications of chronic pelvic and perineal pain and to describe the concepts of chronic pelvic and perineal pain syndrome and the global diagnostic and aetiopathogenic approach. MATERIAL AND METHODS: A review of the literature was performed by searching the Medline database (National Library of Medicine). Search terms were either medical subject heading (MeSH) keywords (classification, complex regional pain syndrome, fibromyalgia, myofascial pain syndrome, neuralgia, pelvic pain, postoperative pain, prostatitis, referred pain, syndrome) or terms derived from the title or abstract. Search terms were used alone or in combinations by using the "AND" operator. The literature search was conducted from 1990 to the present time. RESULTS: Chronic pelvic and perineal pain does not only consist of symptoms localized to an anatomical region present for 3 to 6 months, but also constitutes a distinct, complex, multidimensional disease entity, comprising psychological, organic and psychosomatic phenomena, called chronic pelvic and perineal pain syndromes. These syndromes are responsible for disability, impaired quality of life, and induce considerable health care consumption and sick leave. They alter the patient's personality and affect his or her behaviour, sex life, family life, social life and work life. The usual clinical approach to these syndromes, looking for an organ or tissue disease responsible for pain, is negative. The approach to this type of pain must be much more global and consists of looking for disturbances of the regulation of pelvic and perineal nociceptive messages and dysfunction of the organ or structure concerned. CONCLUSION: The current definitions and classifications of chronic pelvic and perineal pain comprise the concepts of syndrome, functional disease and global approach and differ from the strict organ-based context and the classical medical approach (infectious, inflammatory, metabolic, endocrine) in order to focus pain syndromes on the pain itself and the associated symptoms.

[Medicolegal aspects of chronic pelvic and perineal pain]. / Aspects médicolégaux des douleurs pelvipérinéales chroniques.

OBJECTIVE: To review the medicolegal aspects of chronic pelvic and perineal pain. MATERIAL AND METHODS: The literature and the French Public Health Code were reviewed. The review of the literature was performed by searching the Medline database (National Library of Medicine). Search terms were either medical subject heading (MeSH) keywords (forensic medicine, legislation, pelvic pain, postoperative pain) or terms derived from the title or abstract. Search terms were used alone or in combinations by using the "AND" operator. The literature search was conducted from 1990 to the present time. RESULTS: Chronic pelvic and perineal pain raises a number of medicolegal issues: pain management is required by law, chronic pelvic and perineal pain can be a complication of certain surgical procedures and may be the subject of patient complaints, certain medical or surgical treatments of chronic pelvic and perineal pain do not have a marketing authorisation or scientific validation with a high level of evidence, which can have medicolegal implications. The French law of 4 March 2002 concerning patient rights and quality of the health care system defines a number of legal obligations. All physicians must comply with good professional practices as defined by the code of medical ethics and scientific knowledge. All surgeons are required to provide the patient with honest, clear and appropriate information about the risks of a proposed operation, especially about the possible risk of pain. It is also advised to provide the patient with a written document. All physicians must subscribe a professional civil liability insurance policy. Contraceptive vasectomy, that may be complicated by pain, is a particular case, subject to the French law of 4 July 2001, which requires the surgeon to provide the patient with written information and requires the patient to confirm his request for vasectomy in writing after a 4-month period of reflection. CONCLUSION: The field of chronic pelvic and perineal pain comprises numerous and major medicolegal implications, requiring compliance with good clinical practice and legislation, especially the French law of 4 March 2002 concerning patient rights and quality of the health care system.

[Integration of chronic pelvic pain to the accreditation and professional practice assessment procedures]. / Intégration des douleurs pelvipérinéales chroniques dans la démarche d'accréditation et d'évaluation des pratiques professionnelles.

OBJECTIVE: To list available actions in order to optimize urological care of patients suffering from chronic pelvic and perineal pain, based on guidelines for accreditation and professional practice assessment. MATERIAL AND METHODS: Legislative texts concerning accreditation and PPA, as well as professional recommendations concerning chronic pains have been consulted. RESULTS: Professional practice assessment of chronic pelvic and perineal pain is hampered by the lack of specific professional guidelines. Urological management of chronic pelvic and perineal pain can only be optimized if initial and continued training is strengthened. Furthermore, current professional structures implemented for professional practice assessment and accreditation processes (staff, multi-disciplinary meetings, morbidity-mortality reviews) should be applied in a more systematic way to pelvic chronic pain by urologists. CONCLUSION: The need for improvement in the management of chronic pelvic pain is felt in the urological field, and should lead to developing means of evaluating professional practices, a goal to which the French Urology Association has committed itself.

[Clinical interview and clinical examination of patients with chronic pelvic and perineal pain]. / Interrogatoire et examen clinique d'un patient ayant des douleurs pelvipérinéales chroniques.

INTRODUCTION: Patients with chronic pelvic and perineal pain sometimes report major complaints with no objective value that help to "validate" this pain other than by the patient's own interpretation of the pain. The purpose of this article is to describe the essential elements of the clinical interview and clinical examination in the diagnostic approach to patients with chronic pelvic and perineal pain. PATIENTS AND METHODS: A review of the literature and a description of our experience was performed to describe the clinical interview and clinical examination of patients with chronic pelvic and perineal pain. RESULTS: Clinical interview of the patient is designed to define the characteristics of the pain: mode of installation, topography, irradiation, type, remission, nocturnal waking, and aggravating or limiting factors. It must also look for associated clinical signs: urinary, gastrointestinal, gynaecological, sexual, cutaneous and neurological. The intensity of the pain is evaluated on an analogue scale. A complete clinical examination of the pelvis and perineum must be performed looking for an organic cause: neurological, dermatological, urogenital, spinal, myofascial and sympathetic nervous system. Digital rectal and vaginal (pelvic) examinations play an important role in the detection of trigger points. CONCLUSION: A well-conducted clinical interview and clinical examination can help to elucidate a large proportion of cases of chronic pelvic and perineal pain and are an essential in part of the diagnostic approach.

[Electrophysiological studies of chronic pelvic and perineal pain]. / Explorations électrophysiologiques des douleurs pelvipérinéales chroniques.

OBJECTIVE: To describe electrophysiological studies, what they investigate, and their contribution and limitations in the assessment of pelvic and perineal pain. MATERIAL AND METHOD: Description of the electrophysiological techniques generally used to evaluate somatic nerves of the pelvic and perineal region (analytical electromyography, nerve conduction velocities, reflexology), their applications and the difficulties of interpretation. RESULTS: Electrophysiological studies can demonstrate signs in favour of peripheral neuropathy, specify the axonal and/or demyelinating type of lesion, and provide topographic arguments on the type of trunk or nerve root involved (pudendal nerve, sacral nerve roots, ilioinguinal or iliohypogastric nerve, genitofemoral nerve, obturator nerve). CONCLUSION: Electrophysiological studies require a technically skilled operator and can provide a better understanding of some types of pain, but are not sufficiently sensitive and specific. The conclusions of electrophysiological study reports must be closely correlated with clinical findings.

[Symptomatic approach to chronic pudendal pain]. / Approche symptomatique des douleurs pudendales chroniques.

INTRODUCTION: Pudendal neuralgia is a recently identified and now clearly recognized clinical entity. This chronic disabling pain is due to a pelviperineal tunnel syndrome. MATERIAL AND METHODS: Review of the literature based on a Medline search of articles devoted to this subject. RESULTS: The diagnosis is purely clinical, based on simple consensual criteria (Nantes Criteria): pain situated in the anatomical territory of the pudendal nerve, worse on sitting, not usually waking the patient at night, not accompanied by any objective perineal sensory loss with a positive anaesthetic block of the pudendal nerve at the ischial spine. CONCLUSION: The diagnosis of pudendal neuralgia is straightforward when the patient's symptoms remain confined to these diagnostic criteria, which are all essential for the diagnosis. However, the patient often presents associated urinary, anorectal, sexual, neuromuscular and hypersensitization signs, which can complicate the diagnostic approach and therapeutic management.

[Diagnostic approach to chronic bladder pain]. / Approche symptomatique des douleurs vésicales chroniques.

INTRODUCTION: Painful bladder syndrome is defined as chronic pelvic pain present for more than 6 months, causing discomfort perceived as being related to the bladder and accompanied by a persistent and strong urge to urinate or urinary frequency. The purpose of this article is to review the diagnostic approach to painful bladder syndrome. PATIENTS AND METHODS: A comprehensive review of the literature was performed by searching Pubmed for articles on the diagnostic approach to painful bladder syndrome. RESULTS: Painful bladder syndrome was initially defined by pain related to bladder filling, but now refers to pain related to the bladder accompanied by urinary symptoms (persistent urge or frequency). The diagnosis of painful bladder syndrome is based on clinical interview and a bladder diary. Cystoscopy under general anaesthesia is an essential examination to confirm the diagnosis. Cystoscopy classically demonstrates glomerulations of the bladder mucosa and Hunner's ulcers and simultaneously allows bladder biopsies and bladder hydrodistension, which are the first steps in the management of painful bladder syndrome. The other complementary investigations: imaging, urodynamic assessment, laboratory work-up, cytology are not essential at diagnosis but are useful for the differential diagnosis, as painful bladder syndrome remains a diagnosis of exclusion. CONCLUSION: The diagnosis of painful bladder syndrome is primarily clinical, but is confirmed by cystoscopy in the operating room under anaesthesia with bladder biopsies and a brief trial of hydrodistension.