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.

Chronic Penile Pain: A Poorly Researched and Managed Life-Debilitating Condition.

Chronic penile pain is a complex clinical entity with limited diagnostic criteria and treatment options. Due to limited reporting of these cases, there are no clear clinical treatments and indications for when these patients present to the clinic. This case report will highlight the diagnostic challenges encountered and the subsequent management strategies employed while working up a patient with penile pain. We present a 37-year-old male with a six-year history of debilitating penile pain, urinary frequency, and urgency that is exacerbated by sexual arousal and touch. Initial evaluations attributed the symptoms to medication side effects, leading to medication changes. Despite multiple treatments, including gabapentin, solifenacin, vibegron, and a variety of specialist consultations, the patient's condition persisted. Neurological evaluation revealed pudendal neuropathy. Medical management with pudendal nerve blocks and gabapentin did not provide lasting relief, so surgical interventions were considered. Subsequent treatment with an InterStim II device (Medtronic Inc., Minneapolis, MN) initially resulted in significant symptom improvement. Unfortunately, at the seven-month follow-up, his pain returned. Further evaluation and additional treatment options are currently under consideration. This case report highlights the diagnostic complexity and limited treatment options for chronic penile pain. It suggests that sacral neuromodulation, although lacking long-term data, may offer temporary relief in cases refractory to medical therapy. Further research is needed to enhance our understanding and management of this challenging condition.

Anatomical feasibility of peripheral nerve transfer to reestablish external anal sphincter control - cadaveric study.

PURPOSE: Motor deficits affecting anal sphincter control can severely impair quality of life. Peripheral nerve transfer has been proposed as an option to reestablish anal sphincter motor function. We assessed, in human cadavers, the anatomical feasibility of nerve transfer from a motor branch of the tibialis portion of the sciatic nerve to two distinct points on pudendal nerve (PN), through transgluteal access, as a potential approach to reestablish anal sphincter function. METHODS: We dissected 24 formalinized specimens of the gluteal region and posterior proximal third of the thigh. We characterized the motor fascicle (donor nerve) from the sciatic nerve to the long head of the biceps femoris muscle and the PN (recipient nerve), and measured nerve lengths required for direct coaptation from the donor nerve to the recipient in both the gluteal region (proximal) and perineal cavity (distal). RESULTS: We identified three anatomical variations of the donor nerve as well as three distinct branching patterns of the recipient nerve from the piriformis muscle to the pudendal canal region. Donor nerve lengths (proximal and distal) were satisfactory for direct coaptation in all cases. CONCLUSIONS: Transfer of a motor fascicle of the sciatic nerve to the PN is anatomically feasible without nerve grafts. Donor nerve length was sufficient and donor nerve functionally compatible (motor). Anatomical variations in the PN could also be accommodated.

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

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

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

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

[Magnetic resonance neurography for the identification of pudendal neuralgia]. / Neurografía por resonancia magnética para la identificación de la neuralgia del nervio pudendo.

The pudendal nerve entrapment is an entity understudied by diagnosis imaging. Various causes are recognized in relation to difficult labors, rectal, perineal, urological and gynecological surgery, pelvic trauma fracture, bones tumors and compression by tumors or pelvic pseudotumors. Pudendal neuropathy should be clinically suspected, and confirmed by different methods such as electrofisiological testing: evoked potentials, terminal motor latency test and electromyogram, neuronal block and magnetic resonance imaging. The radiologist should be acquainted with the complex anatomy of the pelvic floor, particularly on the path of pudendal nerve studied by magnetic resonance imaging. High resolution magnetic resonance neurography should be used as a complementary diagnostic study along with clinical and electrophysiological examinations in patients with suspected pudendal nerve neuralgia.

Neurografía por resonancia magnética para la identificación de la neuralgia del nervio pudendo / Magnetic resonance neurography for the identification of pudendal neuralgia

La neuralgia del nervio pudendo (NP) es una entidad poco estudiada por imágenes. Se reconocen varias causas, tales como compresión a través de su paso por estructuras ligamentarias; estiramiento por partos laboriosos; lesiones secundarias a cirugías rectales, perineales, urológicas y ginecológicas, traumatismos con o sin fractura de huesos pelvianos; procesos inflamatorios/autoinmunes; tumores del NP, y, compresión/desplazamiento por tumores o seudotumores de pelvis. El diagnóstico de neuralgia del NP se sospecha por la clínica y se confirma por diferentes métodos, tales como las pruebas electrofisiolológicas: potenciales evocados, test de latencia motora terminal y electromiograma, y, a través de bloqueos neurales y resonancia magnética. La neurografía por resonancia magnética de alta resolución, debería ser empleada como estudio diagnóstico complementario junto a la clínica y exámenes electrofisiológicos, en los pacientes con sospecha de neuralgia del NP.

The pudendal nerve entrapment is an entity understudied by diagnosis imaging. Various causes are recognized in relation to difficult labors, rectal, perineal, urological and gynecological surgery, pelvic trauma fracture, bones tumors and compression by tumors or pelvic pseudotumors. Pudendal neuropathy should be clinically suspected, and confirmed by different methods such as electrofisiological testing: evoked potentials, terminal motor latency test and electromyogram, neuronal block and magnetic resonance imaging. The radiologist should be acquainted with the complex anatomy of the pelvic floor, particularly on the path of pudendal nerve studied by magnetic resonance imaging. High resolution magnetic resonance neurography should be used as a complementary diagnostic study along with clinical and electrophysiological examinations in patients with suspected pudendal nerve neuralgia.

Normative values of skin temperature and thermal sensory thresholds in the pudendal nerve territory.

AIMS: The aim of this study was to define normative values of skin temperature and thermal sensory threshold in the pudendal nerve territory. METHODS: Warm and cold detection thresholds (using the method of limits) and skin temperature were measured in a group of 41 presumably healthy female volunteers aged 41 years (range: 23-66 years) at left thenar eminence and in the pudendal nerve territory. Outlying data were discarded and 95% normative values were derived assuming Normal distributions. RESULTS: Room temperature averaged 24.3 ± 1.1°. Skin temperature and cold detection threshold value were greater anteriorly (clitoris, labia) than posteriorly (para-anal). Para-anal skin temperature and cold detection threshold value were also significantly lower on the right side than on the left side. The warm detection threshold was significantly lower at the clitoris level than at left and right labia. A significant positive effect of skin temperature on cold and warm detection thresholds values was noted especially at thenar and para-anal levels. Age had no effect on skin temperature but warm detection thresholds at clitoris were higher in older subjects. The only qualitative abnormalities observed were after-sensation (4.9%) and habituation (2.8%). Allodynia, dysesthesia, radiation, and dyslocalization were not observed. Two-sided normative values were determined for skin temperature, vertical, and horizontal differences, while one-sided values were derived for cold and warm detection thresholds as well as for their difference. CONCLUSIONS: Normative values for perineal skin temperature and thermal detection thresholds can be used as an alternative non-invasive way to evaluate pudendal neuropathy.

Compound muscle action potential of the external anal sphincter.

AIM: Pudendal nerve terminal motor latency (PNTML) assesses distal innervation of the external anal sphincter (EAS) but it is insensitive to early nerve damage. We propose to extend the assessment of PNTML to the measurement of the compound muscle action potential (CMAP) of the EAS to understand its progressive denervation. METHOD: Ninety women with faecal incontinence were prospectively examined and compared with 36 asymptomatic women who acted as controls. PNTML was performed bilaterally and the muscle response analysed for CMAP to include amplitude, area and duration. Anorectal manometry was measured by a station-pull technique using a water-filled microballoon. spss version 11.5 was used for statistical analysis. RESULTS: In asymptomatic women the CMAP on the left side was greater in nulliparous (n = 7) than parous (n = 27, P < 0.05) individuals. There was a positive correlation with maximum squeeze pressure and area on the left side (P < 0.05, r = 0.397). In women with faecal incontinence, CMAP on the left side had a negative correlation with age (n = 75, P < 0.05), there was no correlation with parity or anorectal manometry. Nulliparous asymptomatic women had a greater CMAP (P < 0.05) on the left side than asymptomatic parous women and parous women with faecal incontinence. Right-side measurements were not conclusive. CONCLUSION: Compound muscle action potential demonstrated progressive denervation with age in women with faecal incontinence but did not reliably identify early signs of denervation in asymptomatic women. The area on the left side related to muscle function in asymptomatic women but not in women with faecal incontinence. CMAP can distinguish between parous women with faecal incontinence and nulliparous asymptomatic women but is not a useful test of function of the EAS.

Methodology of Evaluating the Function of Pudendal Nerve

PURPOSE: Although the pudendal nerve terminal motor latency (PNTML) is normally used, there is no definite test that accurately reflects the function of the pudendal nerve. This study was undertaken to determine the relative accuracy of the various methods in measuring the function of the pudendal nerve. METHODS: Thirty one female patients (age 51.3+/-15.7) with a defecation disorder (constipation 20, fecal incontinence 11) were evaluated prospectively using a neurophysiologic test and balloon reflex manometry. Five parameters such as the right and left PNTML, anal mucosal electrosensitivity, latency and the amplitude of the rectoanal contractile reflex (RACR) were analyzed statistically for their correlation. RESULTS: There was no significant inter-test correlation among the parameters. However, the intra-test correlations between the parameters such as the right and left PNTML (r=0.9629, P<0.001)/latency and the RACR amplitude (r= -0.3770, P=0.0366) were found to be significant. CONCLUSION: The accuracy of these tests in evaluating the pudendal neuropathy could not be determined. However, because it can be assumed that a measurement of the RACR in addition to RNTML is technically accurate, it there will need to be more study for it to be used as an alternative to a PNTML measurement.