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1.
Anesth Analg ; 130(4): 1077-1084, 2020 04.
Artigo em Inglês | MEDLINE | ID: mdl-31490256

RESUMO

BACKGROUND: Neuromodulation, as a therapeutic modality for pain treatment, is an alternative to opioid therapies and therefore receiving increased interest and use. Neuromodulation at a peripheral nerve target, in the form of bilateral electrical pudendal nerve stimulation (bPNS), has been shown to reduce bladder hypersensitivity in rats and anecdotally reduces pain in humans with pelvic pain of urological origin. Recent studies have identified a role for spinal γ-aminobutyric acid (GABA) receptors in this effect. Concomitant medication use, such as benzodiazepines, could alter responses to neuromodulation, and so before the development of a clinical trial to confirm translation of this potential therapy, the potential interactions between acute and chronic use of benzodiazepines and bPNS were examined in a preclinical model. METHODS: Bladder hypersensitivity was produced by neonatal bladder inflammation in rat pups coupled with a second inflammatory insult as an adult. Diazepam (1-5 mg/kg intraperitoneal [i.p.]) or vehicle was administered acutely (with or without bPNS) and chronically (5 mg/kg subcutaneous [s.c.] daily for 2 weeks before the final experiment). bPNS was delivered as bilateral biphasic electrical stimulation of the mixed motor/sensory component of the pudendal nerves. Visceromotor responses (VMRs; abdominal muscle contractile responses to urinary bladder distension [UBD]) were used as nociceptive end points. Due to the profound effects of diazepam, the effect of midazolam (0.5-1.0 mg/kg i.p.) on VMRs and bPNS effects was also studied. RESULTS: Diazepam and midazolam both produced a dose-dependent, flumazenil-reversible inhibition of VMRs to UBD. bPNS resulted in statistically significant inhibition of VMRs to UBD in hypersensitive rats that had received vehicle injections. Select doses of diazepam and midazolam suppressed the inhibitory effect of bPNS on VMRs. CONCLUSIONS: This study suggests that inhibitory effects of bPNS on bladder pain could be suppressed in subjects receiving benzodiazepine therapy, suggesting that potential clinical testing of pudendal nerve stimulation for the treatment of painful bladder syndromes may be confounded by the use of benzodiazepines. Clinical assessment of other forms of neuromodulation should also be screened for impacts of benzodiazepines.


Assuntos
Benzodiazepinas/farmacologia , Nociceptividade/efeitos dos fármacos , Nervo Pudendo/efeitos dos fármacos , Bexiga Urinária/efeitos dos fármacos , Animais , Diazepam/farmacologia , Relação Dose-Resposta a Droga , Estimulação Elétrica , Feminino , Flumazenil/farmacologia , Moduladores GABAérgicos/farmacologia , Midazolam/farmacologia , Neurônios Motores/efeitos dos fármacos , Contração Muscular/efeitos dos fármacos , Músculo Liso/efeitos dos fármacos , Ratos , Ratos Sprague-Dawley , Células Receptoras Sensoriais/efeitos dos fármacos
2.
Paediatr Anaesth ; 29(10): 1046-1052, 2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-31433895

RESUMO

BACKGROUND AND AIMS: Hypospadias is a common congenital malformation in pediatric patients. Surgical repair of this malformation is a painful procedure and has long-term effects. Pudendal and penile nerve blocks are commonly preferred techniques for maintaining postoperative analgesia. However, the conventional landmark-based penile block technique involves numerous potential complications and provides a shorter analgesic period compared to the pudendal block. A promising ultrasound-guided dorsal penile nerve block was recently described. We aimed to compare the analgesic effectiveness of ultrasound-guided penile nerve block with that of neurostimulator-guided pudendal nerve block. METHOD: Thirty-three patients aged 1-7 years were included in this prospective, double-blinded, randomized controlled trial. Patients were divided into two groups and received either ultrasound-guided dorsal penile nerve block or neurostimulator-guided pudendal nerve block. All blocks were performed by the same two anesthesiologists, and the same surgeons performed the surgical procedures. The Face, Legs, Activity, Cry, and Consolability (FLACC) scale was used for postoperative pain management. The primary outcome of the study was time to first analgesic requirement. Secondary outcomes were FLACC scores at different time points, and types and cumulative doses of analgesic drugs. RESULTS: Dorsal penile nerve block provided longer analgesia than pudendal nerve block (32.29 ± 5.47 hours and 21.13 ± 3.53 hours, respectively; differences in mean: 11.16, 95% CI: 7.873-14.465) (P < .001). FLACC scores at the time of first analgesic requirement were significantly lower in dorsal penile nerve block group than pudendal nerve block group (median [IQR]: 2 [2-2.5] and 3 [3-5], respectively; differences in median: -1, 95% CI: -1.851 to -0.149) (P < .001). CONCLUSION: Ultrasound-guided dorsal penile nerve block provided a longer analgesic period and reduced opioid consumption compared to neurostimulator-guided pudendal nerve block.


Assuntos
Anestésicos Locais/administração & dosagem , Hipospadia/cirurgia , Bloqueio Nervoso/métodos , Nervo Pudendo/efeitos dos fármacos , Ultrassonografia , Analgesia , Criança , Pré-Escolar , Humanos , Masculino , Pênis/diagnóstico por imagem , Estudos Prospectivos , Distribuição Aleatória
3.
Pain Physician ; 22(4): E333-E344, 2019 07.
Artigo em Inglês | MEDLINE | ID: mdl-31337177

RESUMO

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


Assuntos
Bloqueio Nervoso/métodos , Neuralgia do Pudendo/diagnóstico , Neuralgia do Pudendo/tratamento farmacológico , Radiografia Intervencionista/métodos , Adulto , Idoso , Idoso de 80 Anos ou mais , Anestésicos Locais/administração & dosagem , Estudos Transversais , Feminino , Humanos , Imagem por Ressonância Magnética/métodos , Masculino , Pessoa de Meia-Idade , Dor Pélvica/tratamento farmacológico , Dor Pélvica/etiologia , Nervo Pudendo/diagnóstico por imagem , Nervo Pudendo/efeitos dos fármacos , Estudos Retrospectivos , Tomografia Computadorizada por Raios X/métodos
4.
Int J Urol ; 26(8): 833-838, 2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-31209957

RESUMO

OBJECTIVES: To compare the efficacy, safety and cost of combinations of perineal pudendal nerve block + periprostatic nerve block and intrarectal local anesthesia + periprostatic nerve block with the standard technique (periprostatic nerve block). METHODS: The study was designed as a randomized prospective controlled trial. Patients with elevated serum prostate-specific antigen values (prostate-specific antigen ≥4 ng/mL) and/or abnormal digital rectal examination findings were included in the study. Patients with anorectal diseases, chronic prostatitis, previous history of prostate biopsy and anorectal surgery were excluded from the study. A total of 148 patients (group 1 [periprostatic nerve block], n = 48; group 2 [intrarectal local anesthesia + periprostatic nerve block], n = 51; group 3 [perineal pudendal nerve block + periprostatic nerve block], n = 49) were included in the final analysis. Pain during insertion and manipulation of the transrectal ultrasound probe was recorded as visual analog scale 1, pain during penetration of the biopsy needle into the prostate and sampling was recorded as visual analog scale 2, and pain during the entire procedure recorded as visual analog scale 3. RESULTS: The mean visual analog scale 1 score was significantly lower in group 3, when compared with group 1 and group 2 (P < 0.001). There was no significant difference between the groups in terms of the mean visual analog scale 2 score. The mean visual analog scale 3 score was significantly lower in group 3 when compared with other groups (P < 0.001). The total cost for transrectal ultrasound-guided biopsy in the intrarectal local anesthesia + periprostatic nerve block group was significantly higher than the other two groups. CONCLUSIONS: The combination of perineal pudendal nerve block and periprostatic nerve block provides more effective pain control than intrarectal local anesthesia plus periprostatic nerve block and periprostatic nerve block alone, with similar complication rates and without increasing cost.


Assuntos
Anestesia Local/métodos , Bloqueio Nervoso/métodos , Dor Processual/prevenção & controle , Neoplasias da Próstata/diagnóstico , Idoso , Anestesia Local/efeitos adversos , Anestesia Local/economia , Anestésicos Locais/administração & dosagem , Anestésicos Locais/economia , Biópsia com Agulha de Grande Calibre/efeitos adversos , Biópsia com Agulha de Grande Calibre/economia , Biópsia com Agulha de Grande Calibre/métodos , Análise Custo-Benefício , Humanos , Biópsia Guiada por Imagem/efeitos adversos , Biópsia Guiada por Imagem/economia , Biópsia Guiada por Imagem/métodos , Lidocaína/administração & dosagem , Lidocaína/economia , Masculino , Pessoa de Meia-Idade , Bloqueio Nervoso/efeitos adversos , Bloqueio Nervoso/economia , Medição da Dor/estatística & dados numéricos , Dor Processual/diagnóstico , Dor Processual/etiologia , Próstata/diagnóstico por imagem , Próstata/patologia , Neoplasias da Próstata/patologia , Nervo Pudendo/efeitos dos fármacos , Reto/cirurgia , Ultrassonografia de Intervenção/economia
5.
Biomed Res Int ; 2019: 6875756, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31032356

RESUMO

Background: General anesthesia combining with a caudal block (CB) has been commonly performed in pediatric patients undergoing circumcision surgeries. However, some severe complications have been suspected of a caudal block in the combined use. To avoid these issues of a caudal block, this study introduces a novel dorsal penile nerve block (DPNB) via perineum guided by ultrasound as an alternative to a caudal block in pediatric circumcision surgeries. Methods: A total of 104 pediatric patients scheduled for circumcision surgeries were involved and randomly divided into 2 groups: the CB group (n=52) and the DPNB group (n=52). A laryngeal mask was inserted followed by induction and maintenance anesthesia of inhaled sevoflurane. In the DPNB group, a dorsal penile nerve block (DPNB) guided by a real-time ultrasonography was performed by a single injection via perineum of 0.25% ropivacaine plus 0.8% lidocaine with total injection volume of 3-5ml. In the CB group, a dose of 0.5 ml/kg was given via the caudal canal following the same general anesthesia with that of Group DPNB. The time to the first analgesic demand after surgery is the key data collected for comparing between the two study groups. Heart rates and respiratory rates changes before and during the surgical procedure, pain score when leaving the PACU, and the time taken for the first micturition after a surgery were also recorded to analyze the differences in analgesic effects between the CB and DPNB groups. Results: No significant difference in heart rates and respiratory rates was found between the two groups before and during the surgery. Pain scores were similar before pediatric patients leave the PACU. However, the time taken for the first micturition after a surgery in Group DPNB is shorter than Group CB. The patients in Group DPNB asked for analgesics later than those in Group CB. Additionally, no significant differences in adverse effects were noted between two groups except the numbness of the lower limbs occurring less in Group DPNB. Conclusions: The ultrasound-guided dorsal penile nerve block via perineal approach can basically act as a safe and effective alternative to the caudal block in pediatric patients undergoing circumcision surgeries. Clinical Trials identifier is ChiCTR-IPR-15006670. Protocol is available at http://www.chictr.org.cn/showproj.aspx?proj=11319.


Assuntos
Anestesia Geral/métodos , Circuncisão Masculina/métodos , Pênis/cirurgia , Nervo Pudendo/efeitos dos fármacos , Criança , Pré-Escolar , Humanos , Lidocaína/administração & dosagem , Masculino , Bloqueio Nervoso/métodos , Medição da Dor/métodos , Pênis/inervação , Ropivacaina/administração & dosagem
7.
Neurosci Lett ; 686: 181-185, 2018 11 01.
Artigo em Inglês | MEDLINE | ID: mdl-30218768

RESUMO

Bilateral electrical pudendal nerve stimulation (bPNS) reduces bladder hypersensitivity in rat models of bladder pain and anecdotally reduces pain in humans with pelvic pain of urologic origin. The spinal neurochemical mechanisms of this antinociception are unknown. In the present study, bladder hypersensitivity was produced by neonatal bladder inflammation in rat pups coupled with a second inflammatory insult as an adult. Visceromotor responses (VMRs; abdominal muscle contractions) to urinary bladder distension (UBD) were used as a nociceptive endpoint under urethane-isoflurane anesthesia. bPNS consisted of bilateral biphasic electrical stimulation of the mixed motor/sensory component of the pudendal nerves. Following determination of the inhibitory effect of bPNS on VMRs, pharmacological antagonists were administered via an intrathecal catheter onto the lumbosacral spinal cord and bPNS effects on VMRs redetermined. bPNS resulted in statistically significant inhibition of VMRs to UBD in hypersensitive rats that was statistically reduced by the intrathecal administration of methysergide, WAY100636, CGP35348 and strychnine but was unaffected by naloxone, bicuculline, phentolamine, ondansetron and normal saline. This study suggests that inhibitory effects of bPNS may include serotonergic, GABA-B-ergic and glycinergic mechanisms suggesting the potential for interaction of the neuromodulatory effect with concommitant drug therapies.


Assuntos
Estimulação Elétrica , Contração Muscular/efeitos dos fármacos , Naloxona/farmacologia , Dor/tratamento farmacológico , Nervo Pudendo/efeitos dos fármacos , Animais , Cicloexanos/farmacologia , Estimulação Elétrica/métodos , Feminino , Piperazinas/farmacologia , Ratos Sprague-Dawley , Reflexo/efeitos dos fármacos , Medula Espinal/efeitos dos fármacos , Bexiga Urinária/inervação
8.
Paediatr Anaesth ; 28(8): 703-709, 2018 08.
Artigo em Inglês | MEDLINE | ID: mdl-30035357

RESUMO

BACKGROUND AND AIMS: Circumcision is a frequently performed procedure in day case pediatric surgery. Dorsal penile nerve block has proven its effectiveness for the management of acute postoperative pain after circumcision. We investigated if the ultrasound-guided placement of a dorsal penile nerve block could reduce opioid requirement as compared to a landmark-based technique. METHODS: Three hundred and ten prepubertal children, aged between 52 weeks postconception and 11 years, were included in this prospective, observer-blinded, randomized controlled trial and received either a landmark- or an ultrasound-guided dorsal penile nerve block, using a caudal needle and injecting 0.1 mL/kg levobupivacaine 0.5% bilaterally. A single, experienced investigator performed all blocks. The primary endpoint was the number of patients in need of piritramide postoperatively as triggered by the Objective Pain Scale. Secondary outcome parameters included the cumulative dose of postoperatively administered opioids, the requirement to administer fentanyl intraoperatively, the need for paracetamol and ibuprofen during the first 24 postoperative hours, postoperative pain scores, the incidence of postoperative nausea and vomiting, the anesthesia induction time, and the time to discharge. RESULTS: The proportion of patients requiring postoperative piritramide did not differ significantly between both groups (Landmark: 38% vs Ultrasound: 47%, with a difference in proportion between both conditions (95% CI): 0.09 (0.2 to 0.02); P = .135). In addition, the cumulative doses of postoperative piritramide and intraoperative fentanyl, the postoperative need for paracetamol or ibuprofen, pain scores, the incidence of postoperative nausea and vomiting, and the time to discharge were not different either. However, the anesthesia induction time was significantly longer in the ultrasound-guided dorsal penile nerve block (median time [IQR]: Landmark: 11[9; 13] min vs Ultrasound: 13[11; 15] min, P < .001). CONCLUSION: Compared with the landmark-guided, the ultrasound-guided dorsal penile nerve block did not reduce the need for postoperative analgesia after circumcision in children, but was associated with an increase in the procedural time.


Assuntos
Circuncisão Masculina/métodos , Bloqueio Nervoso/métodos , Dor Pós-Operatória/terapia , Nervo Pudendo/efeitos dos fármacos , Ultrassonografia de Intervenção/métodos , Pontos de Referência Anatômicos , Anestesia Local/métodos , Criança , Pré-Escolar , Humanos , Lactente , Masculino , Medição da Dor , Assistência Perioperatória/métodos , Cuidados Pós-Operatórios/métodos
10.
Pain Physician ; 21(1): 83-90, 2018 01.
Artigo em Inglês | MEDLINE | ID: mdl-29357337

RESUMO

BACKGROUND: Pudendal neuralgia (PN) is a very painful and often disabling condition in which pudendal nerve blocks play an important role in both the diagnosis and management of PN. Some previous reports have advocated the use of pudendal nerve infiltration (PNI) as a diagnostic test only. OBJECTIVE: We aim to assess the outcomes of patients with typical refractory PN who underwent dual site computed tomography (CT)-guided pudendal nerve infiltration. STUDY DESIGN: A bicentric, retrospective cohort analysis. SETTING: An academic practice. METHODS: Between 2002 and 2016, 385 PNIs were performed in 195 patients in the 2 units. Only patients suffering from typical clinical PN were included, and only the first infiltration in each patient was considered for analysis. Therefore, 95 patients who underwent 155 procedures were assessed. Pain was assessed using a visual analog scale (0-10) and self-reported estimated improvement (SRI), expressed as a percentage. Efficacy of the procedure was assessed at 1, 3, and 6 months after procedure follow-up, and clinical success was defined as a 50% decrease of the VAS score. All procedures were performed under CT guidance and on an outpatient basis. Dual site infiltration was performed in each case at both the ischial spine and intra-Alcock's canal sites using a mixture of fast- and slow-acting anesthetic (1 mL lidocaine hydrochloride 1% and 2 mL ropivacaine chlorhydrate) along with a half dose of 1.5 mL of cortivazol (3.75 mg). RESULTS: Clinical success at one month post-procedure was present in 63.2% of patients (60/95) with a mean VAS score of 2.07 (P < 0.05) and a mean SRI of 71%. At 3 months follow-up, clinical success was still present in 50.5% of patients (48/95) with a mean VAS score of 2.90/10 (P < 0.05) and a mean SRI of 62.3%. At 6 months follow-up, the efficacy rate decreased to 25.2% with a mean VAS score of 3.2/10 and SRI of 60%. LIMITATIONS: The retrospective aspect of the study is a limitation, as well as the lack of a control group. CONCLUSION: Dual site PNI under CT guidance may offer significant mid-term pain relief to a majority of patients suffering from typical refractory PN. KEY WORDS: Pudendal nerve, neuralgia, block, Alcock, CT, guidance.


Assuntos
Bloqueio Nervoso/métodos , Manejo da Dor/métodos , Nervo Pudendo/efeitos dos fármacos , Neuralgia do Pudendo/tratamento farmacológico , Radiografia Intervencionista/métodos , Adulto , Idoso , Estudos de Coortes , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Tomografia Computadorizada por Raios X/métodos
11.
J Coll Physicians Surg Pak ; 27(12): 783-784, 2017 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-29185409

RESUMO

Methemoglobin (MetHb) is a form of hemoglobin which contains iron in ferric state. The delivery of oxygen to tissues is impaired and cellular hypoxia develops with an increase in MetHb levels. Methemoglobinemia is a rare but potentially lethal complication of local anesthetics. In this clinical brief, three cases of transient neonatal methemoglobinemia, caused by maternal pudendal anesthesia with prilocaine, are reported.


Assuntos
Anestesia Local , Anestesia Obstétrica/efeitos adversos , Anestésicos Locais/efeitos adversos , Sangue Fetal/efeitos dos fármacos , Metemoglobinemia/induzido quimicamente , Bloqueio Nervoso , Prilocaína/efeitos adversos , Nervo Pudendo , Cianose , Feminino , Sangue Fetal/metabolismo , Humanos , Recém-Nascido , Masculino , Gravidez , Prilocaína/administração & dosagem , Nervo Pudendo/efeitos dos fármacos , Resultado do Tratamento , Adulto Jovem
13.
J Steroid Biochem Mol Biol ; 171: 229-235, 2017 07.
Artigo em Inglês | MEDLINE | ID: mdl-28408350

RESUMO

Recent reports show that, in patients treated with finasteride for male pattern hair loss, persistent side effects including sexual side effects, depression, anxiety and cognitive complaints may occur. We here explored the psychiatric and andrological features of patients affected by post-finasteride syndrome (PFS) and verified whether the cerebrospinal fluid (CSF) and plasma levels of neuroactive steroids (i.e., important regulators of nervous function) are modified. We found that eight out of sixteen PFS male patients considered suffered from a DSM-IV major depressive disorder (MDD). In addition, all PFS patients showed erectile dysfunction (ED); in particular, ten patients showed a severe and six a mild-moderate ED. We also reported abnormal somatosensory evoked potentials of the pudendal nerve in PFS patients with severe ED, the first objective evidence of a neuropathy involving peripheral neurogenic control of erection. Testicular volume by ultrasonography was normal in PFS patients. Data obtained on neuroactive steroid levels also indicate interesting features. Indeed, decreased levels of pregnenolone, progesterone and its metabolite (i.e., dihydroprogesterone), dihydrotestosterone and 17beta-estradiol and increased levels of dehydroepiandrosterone, testosterone and 5alpha-androstane-3alpha,17beta-diol were observed in CSF of PFS patients. Neuroactive steroid levels were also altered in plasma of PFS patients, however these changes did not reflect exactly what occurs in CSF. Finally, finasteride did not only affect, as expected, the levels of 5alpha-reduced metabolites of progesterone and testosterone, but also the further metabolites and precursors suggesting that this drug has broad consequence on neuroactive steroid levels of PFS patients.


Assuntos
Inibidores de 5-alfa Redutase/efeitos adversos , Transtorno Depressivo Maior/induzido quimicamente , Disfunção Erétil/induzido quimicamente , Finasterida/efeitos adversos , Pregnenolona/líquido cefalorraquidiano , Progesterona/líquido cefalorraquidiano , Testosterona/líquido cefalorraquidiano , Inibidores de 5-alfa Redutase/uso terapêutico , Adulto , Alopecia/tratamento farmacológico , Estudos de Casos e Controles , Transtorno Depressivo Maior/sangue , Transtorno Depressivo Maior/líquido cefalorraquidiano , Transtorno Depressivo Maior/epidemiologia , Manual Diagnóstico e Estatístico de Transtornos Mentais , Monitoramento de Medicamentos , Disfunção Erétil/epidemiologia , Disfunção Erétil/metabolismo , Disfunção Erétil/fisiopatologia , Potenciais Somatossensoriais Evocados/efeitos dos fármacos , Finasterida/uso terapêutico , Humanos , Incidência , Itália/epidemiologia , Estudos Longitudinais , Masculino , Pregnenolona/sangue , Progesterona/análogos & derivados , Progesterona/sangue , Estudos Prospectivos , Escalas de Graduação Psiquiátrica , Nervo Pudendo/efeitos dos fármacos , Nervo Pudendo/fisiopatologia , Neuralgia do Pudendo/induzido quimicamente , Neuralgia do Pudendo/epidemiologia , Neuralgia do Pudendo/metabolismo , Neuralgia do Pudendo/fisiopatologia , Índice de Gravidade de Doença , Testosterona/análogos & derivados , Testosterona/sangue , Adulto Jovem
14.
J Clin Ultrasound ; 45(9): 589-591, 2017 Nov 12.
Artigo em Inglês | MEDLINE | ID: mdl-28186626

RESUMO

Injury to the penis resulting from zipper entrapment is a painful condition that presents a unique anesthetic challenge to the emergency physician and may even require procedural sedation for removal. In this case report, we describe successful removal of zipper entrapment from the penis of a 34-year-old patient after the application of an ultrasound-guided dorsal penile nerve block. We discuss the anatomy, sonographic features, and steps required for the nerve block procedure. © 2017 Wiley Periodicals, Inc. J Clin Ultrasound 45:589-591, 2017.


Assuntos
Prepúcio do Pênis/diagnóstico por imagem , Prepúcio do Pênis/lesões , Bloqueio Nervoso/métodos , Doenças do Pênis/patologia , Nervo Pudendo/diagnóstico por imagem , Ultrassonografia de Intervenção/métodos , Adulto , Anestésicos Locais/administração & dosagem , Antibacterianos/uso terapêutico , Bacitracina/uso terapêutico , Prepúcio do Pênis/patologia , Humanos , Lidocaína/administração & dosagem , Masculino , Necrose , Doenças do Pênis/diagnóstico , Doenças do Pênis/tratamento farmacológico , Pênis/diagnóstico por imagem , Pênis/lesões , Pênis/inervação , Nervo Pudendo/efeitos dos fármacos
15.
J Clin Anesth ; 34: 668-75, 2016 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-27687468

RESUMO

STUDY OBJECTIVE: Compare the effectiveness of nerve stimulator-guided pudendal nerve block (PNB) vs general anesthesia (GA) for anterior and posterior (AP) colporrhaphy in terms of pain relief and analgesic consumption within 24 and 48 hours postoperatively. DESIGN: Prospective randomized trial. PATIENTS: Fifty-seven patients whose ages ranged between 20 and 53 years scheduled to undergo AP colporrhaphy due to the presence of cystorectocele. INTERVENTIONS: Patients were randomly assigned into 2 groups receiving either nerve stimulator-guided PNB (n = 28) or GA (n = 29). A total volume of 0.7 mL/kg of the local anesthetic mixture was injected at 4 sites. MAIN RESULTS: Both groups were similar with respect to age, weight, height, and surgery duration. There was a significant difference in average pain scores within the first and second postoperative days (P values = .005 and .004, respectively). Total analgesic consumption (ketoprofen and tramadol) was significantly lower in the PNB within the first (P values = .018 and .010) and second postoperative days (P values = .041 and .011), respectively. Return to normal daily activity was significantly (P< .0001) shorter in the PNB group compared with the GA group (3.6 days vs 12.2 days). A total of 71.4% of the patients in the PNB group were satisfied compared with 27.8% in the GA group (P< .0001). Surgeon satisfaction was significantly higher in the PNB group (82.1% vs 34.5%, P< .0001). CONCLUSION: This randomized controlled trial demonstrated that nerve stimulator-guided PNB could be used as an alternative to GA for AP repair of stages I and II prolapse because it is associated with less postoperative pain and analgesic consumption, in addition to shorter duration of recovery.


Assuntos
Cistocele/cirurgia , Procedimentos Cirúrgicos em Ginecologia/efeitos adversos , Bloqueio Nervoso/métodos , Manejo da Dor/métodos , Dor Pós-Operatória/tratamento farmacológico , Nervo Pudendo/efeitos dos fármacos , Retocele/cirurgia , Vagina/cirurgia , Adulto , Idoso , Anestesia Geral , Anestésicos Locais/administração & dosagem , Estimulação Elétrica , Feminino , Humanos , Pessoa de Meia-Idade , Medição da Dor , Satisfação do Paciente , Estudos Prospectivos , Fatores de Tempo , Resultado do Tratamento
16.
Pain Physician ; 19(4): 299-306, 2016 05.
Artigo em Inglês | MEDLINE | ID: mdl-27228517

RESUMO

BACKGROUND: Pudendal neuropathy is a tunnel syndrome characterized by pelvic pain and may include bowel, bladder, or sexual dysfunction or a combination of these. One treatment method, pudendal nerve perineural injections (PNPIs), uses infiltration of bupivacaine and corticosteroid around the nerve to provide symptom relief. Bupivacaine also anesthetizes the skin in the receptive field of the nerve that is injected. Bupivacaine offers rapid pain relief for several hours while corticosteroid provides delayed pain control often lasting 3 to 5 weeks. Not all pudendal nerve blocks may provide complete pain relief but long-term pain control from the steroid appears to be associated with immediate response to bupivacaine. We offer a method of evaluating the quality of a pudendal block on the day it is performed using pinprick sensation evaluation. OBJECTIVE: To demonstrate that pinprick sensory changes provide a simple and rapid method of measuring response to local anesthetic and pain reduction provided by a PNPI on the day it is performed. This response defines the quality of each PNPI. STUDY DESIGN: This is a case series based on retrospective review of a private practice database that is maintained by HealthEast hospitals in Minnesota. Database information includes standard physical examination, recording techniques, and treatment processes that had been in place for several years. SETTING: Private practice in United States. METHODS: Patients with a diagnosis of pudendal neuropathy are treated with PNPIs. Two hours after each block, 2 endpoints are measured: response to a sensory pinprick examination of the pudendal territory and difference in patient-reported pain level before and after nerve block. Fifty-three men from a private practice treating only pelvic pain received the treatment in 2005. Reported pain level was not recorded for 2 patients. RESULTS: Bupivacaine in perineural injections produces varying degrees of analgesia or hypalgesia to pinprick. Normal pinprick response suggests pudendal nerves were not penetrated by bupivacaine. Patient responses varied from complete, i.e. all 6 branches anesthetized to none. Most men had 2 - 5 nerve branches anesthetized. One man had a single nerve branch that responded to bupivacaine. Three men failed to respond to local anesthetic.Changes in pre-PNPI to post-PNPI pain scores were significantly decreased (n = 51, P-value < 0.0001), indicating that bupivacaine in the PNPI reduced pain. Forty-one patients (80.4%) indicated less pain after the procedure and only 2 patients (4.0%) indicated more pain. The number of nerve branches successfully anesthetized was also significantly correlated with change in score. On average, an additional successful nerve branch anesthetized corresponded to a drop of about 0.66 in the change score (n = 51, P - value = 0.0005). CONCLUSION: PNPIs relieve pain. Anesthesia affected all 6 pudendal nerve branches in only 13.2% of patients. Complete pain relief occurred in 39.2%. This argues against use of perineural pudendal blockade as a diagnostic test. Pain relief after PNPI is associated with number of nerve branches that are anesthetized. At 2 hours after a PNPI its quality (the number of the 6 nerve branches with reduced response to pinprick from the perineural local anesthetic) is associated with subjective reduction of pain. KEY WORDS: Pudendal neuralgia, chronic perineal pain, pudendal nerve block, sensory examination, neurologic examination, pain management, chronic pelvic pain syndrome.


Assuntos
Anestésicos Locais/farmacologia , Bloqueio Nervoso Autônomo/métodos , Bupivacaína/farmacologia , Avaliação de Resultados em Cuidados de Saúde , Dor Pélvica/tratamento farmacológico , Nervo Pudendo/efeitos dos fármacos , Neuralgia do Pudendo/tratamento farmacológico , Adulto , Anestésicos Locais/administração & dosagem , Bupivacaína/administração & dosagem , Humanos , Injeções , Masculino , Dor Pélvica/etiologia , Neuralgia do Pudendo/complicações , Estudos Retrospectivos
17.
Neurourol Urodyn ; 35(7): 798-804, 2016 09.
Artigo em Inglês | MEDLINE | ID: mdl-26147494

RESUMO

AIM: This study examined the role of glycinergic transmission in nociceptive and non-nociceptive bladder reflexes and in inhibition of these reflexes by pudendal nerve stimulation (PNS). METHODS: Cystometrograms (CMGs) were performed in α-chloralose anesthetized cats by intravesical infusion of saline or 0.25% acetic acid (AA) to trigger, respectively, non-nociceptive or nociceptive bladder reflexes. PNS at 2 or 4 times threshold (T) intensity for inducing anal twitch was used to inhibit the bladder reflexes. Strychnine (a glycine receptor antagonist) was administered in cumulative doses (0.001-0.3 mg/kg, i.v.) at 60-120 min intervals. RESULTS: Strychnine at 0.001-0.3 mg/kg significantly (P < 0.05) increased bladder capacity and reduced contraction amplitude during saline CMGs but did not change these parameters during AA CMGs except at the 0.3 mg/kg dose which increased bladder capacity. Strychnine did not alter PNS inhibition during saline CMGs except at the highest dose at 2T intensity, but significantly (P < 0.05) suppressed PNS inhibition during AA CMGs after 0.001-0.003 mg/kg doses at 2T and 4T intensities. During AA CMGs strychnine (0.3 mg/kg) also unmasked a post-PNS excitatory effect that significantly reduced bladder capacity after termination of PNS. CONCLUSIONS: Glycinergic inhibitory neurotransmission in the central nervous system plays an unexpected role to tonically enhance the magnitude and reduce the bladder volume threshold for triggering the non-nociceptive bladder reflex. This is attributable to inhibition by glycine of another inhibitory mechanism. Glycine also has a minor role in PNS inhibition of the nociceptive bladder reflex. Neurourol. Urodynam. 35:798-804, 2016. © 2015 Wiley Periodicals, Inc.


Assuntos
Glicina/fisiologia , Nociceptividade/fisiologia , Nervo Pudendo/fisiologia , Reflexo/fisiologia , Bexiga Urinária/fisiologia , Animais , Gatos , Estimulação Elétrica , Feminino , Glicinérgicos/farmacologia , Masculino , Contração Muscular/efeitos dos fármacos , Contração Muscular/fisiologia , Nociceptividade/efeitos dos fármacos , Nervo Pudendo/efeitos dos fármacos , Receptores da Glicina/antagonistas & inibidores , Reflexo/efeitos dos fármacos , Estricnina/farmacologia , Bexiga Urinária/efeitos dos fármacos , Bexiga Urinária/inervação
18.
Am J Physiol Renal Physiol ; 309(3): F242-50, 2015 Aug 01.
Artigo em Inglês | MEDLINE | ID: mdl-26017973

RESUMO

This study examined the role of the brain stem in inhibition of bladder reflexes induced by tibial nerve stimulation (TNS) in α-chloralose-anesthetized decerebrate cats. Repeated cystometrograms (CMGs) were performed by infusing saline or 0.25% acetic acid (AA) to elicit normal or overactive bladder reflexes, respectively. TNS (5 or 30 Hz) at three times the threshold (3T) intensity for inducing toe movement was applied for 30 min between CMGs to induce post-TNS inhibition or applied during the CMGs to induce acute TNS inhibition. Inhibition was evident as an increase in bladder capacity without a change in amplitude of bladder contractions. TNS applied for 30 min between saline CMGs elicited prolonged (>2 h) poststimulation inhibition that significantly (P < 0.05) increased bladder capacity to 30-60% above control; however, TNS did not produce this effect during AA irritation. TNS applied during CMGs at 5 Hz but not 30 Hz significantly (P < 0.01) increased bladder capacity to 127.3 ± 6.1% of saline control or 187.6 ± 5.0% of AA control. During AA irritation, naloxone (an opioid receptor antagonist) administered intravenously (1 mg/kg) or directly to the surface of the rostral brain stem (300-900 µg) eliminated acute TNS inhibition and significantly (P < 0.05) reduced bladder capacity to 62.8 ± 22.6% (intravenously) or 47.6 ± 25.5% (brain stem application). Results of this and previous studies indicate 1) forebrain circuitry rostral to the pons is not essential for TNS inhibition; and 2) opioid receptors in the brain stem have a critical role in TNS inhibition of overactive bladder reflexes but are not involved in inhibition of normal bladder reflexes.


Assuntos
Tronco Encefálico/fisiologia , Reflexo/fisiologia , Nervo Tibial/fisiologia , Micção/fisiologia , Ácido Acético , Animais , Gatos , Estado de Descerebração/fisiopatologia , Estimulação Elétrica , Feminino , Masculino , Naloxona/farmacologia , Antagonistas de Entorpecentes/farmacologia , Nervo Pudendo/efeitos dos fármacos , Bexiga Urinária/inervação , Bexiga Urinária/fisiopatologia , Bexiga Urinária Hiperativa/induzido quimicamente , Bexiga Urinária Hiperativa/fisiopatologia
19.
Int J Radiat Oncol Biol Phys ; 91(4): 796-806, 2015 Mar 15.
Artigo em Inglês | MEDLINE | ID: mdl-25752394

RESUMO

PURPOSE/OBJECTIVES: Erectile dysfunction is common after radiation therapy for prostate cancer; yet, the etiopathology of radiation-induced erectile dysfunction (RI-ED) remains poorly understood. A novel animal model was developed to study RI-ED, wherein stereotactic body radiation therapy (SBRT) was used to irradiate the prostate, neurovascular bundles (NVB), and penile bulb (PB) of dogs. The purpose was to describe vascular and neurogenic injuries after the irradiation of only the NVB or the PB, and after irradiation of all 3 sites (prostate, NVB, and PB) with varying doses of radiation. METHODS AND MATERIALS: Dogs were treated with 50, 40, or 30 Gy to the prostate, NVB, and PB, or 50 Gy to either the NVB or the PB, by 5-fraction SBRT. Electrophysiologic studies of the pudendal nerve and bulbospongiosus muscles and ultrasound studies of pelvic perfusion were performed before and after SBRT. The results of these bioassays were correlated with histopathologic changes. RESULTS: SBRT caused slowing of the systolic rise time, which corresponded to decreased arterial patency. Alterations in the response of the internal pudendal artery to vasoactive drugs were observed, wherein SBRT caused a paradoxical response to papaverine, slowing the systolic rise time after 40 and 50 Gy; these changes appeared to have some dose dependency. The neurofilament content of penile nerves was also decreased at high doses and was more profound when the PB was irradiated than when the NVB was irradiated. These findings are coincident with slowing of motor nerve conduction velocities in the pudendal nerve after SBRT. CONCLUSIONS: This is the first report in which prostatic irradiation was shown to cause morphologic arterial damage that was coincident with altered internal pudendal arterial tone, and in which decreased motor function in the pudendal nerve was attributed to axonal degeneration and loss. Further investigation of the role played by damage to these structures in RI-ED is warranted.


Assuntos
Modelos Animais de Doenças , Disfunção Erétil/etiologia , Pênis/efeitos da radiação , Próstata/efeitos da radiação , Nervo Pudendo/efeitos da radiação , Radiocirurgia/efeitos adversos , Animais , Artérias/patologia , Artérias/efeitos da radiação , Cães , Disfunção Erétil/tratamento farmacológico , Impotência Vasculogênica/tratamento farmacológico , Impotência Vasculogênica/etiologia , Masculino , Pênis/irrigação sanguínea , Pênis/inervação , Próstata/irrigação sanguínea , Próstata/inervação , Nervo Pudendo/efeitos dos fármacos , Nervo Pudendo/patologia , Nervo Pudendo/fisiopatologia , Doses de Radiação , Radiocirurgia/métodos , Sístole/fisiologia , Sístole/efeitos da radiação , Veias/patologia , Veias/efeitos da radiação
20.
Am J Physiol Renal Physiol ; 308(8): F832-8, 2015 Apr 15.
Artigo em Inglês | MEDLINE | ID: mdl-25673810

RESUMO

This study examined the role of spinal metabotropic glutamate receptor 5 (mGluR5) in the nociceptive C-fiber afferent-mediated spinal bladder reflex and in the inhibtion of this reflex by pudendal nerve stimulation (PNS). In α-chloralose-anesthetized cats after spinal cord transection at the T9/T10 level, intravesical infusion of 0.25% acetic acid irritated the bladder, activated nociceptive C-fiber afferents, and induced spinal reflex bladder contractions of low amplitude (<50 cmH2O) and short duration (<20 s) at a smaller bladder capacity ∼80% of saline control capacity. PNS significantly (P < 0.01) increased bladder capacity from 85.5 ± 10.1 to 137.3 ± 14.1 or 148.2 ± 11.2% at 2T or 4T stimulation, respectively, where T is the threshold intensity for PNS to induce anal twitch. MTEP {3-[(2-methyl-4-thiazolyl)ethynyl]pyridine; 3 mg/kg iv, a selective mGluR5 antagonist} completely removed the PNS inhibition and significantly (P < 0.05) increased bladder capacity from 71.8 ± 9.9 to 94.0 ± 13.9% of saline control, but it did not change the bladder contraction amplitude. After propranolol (3 mg/kg iv, a ß1/ß2-adrenergic receptor antagonist) treatment, PNS inhibition remained but MTEP significantly (P < 0.05) reduced the bladder contraction amplitude from 18.6 ± 2.1 to 6.6 ± 1.2 cmH2O and eliminated PNS inhibition. At the end of experiments, hexamethonium (10 mg/kg iv, a ganglionic blocker) significantly (P < 0.05) reduced the bladder contraction amplitude from 20.9 ± 3.2 to 8.1 ± 1.5 cmH2O on average demonstrating that spinal reflexes were responsible for a major component of the contractions. This study shows that spinal mGluR5 plays an important role in the nociceptive C-fiber afferent-mediated spinal bladder reflex and in pudendal inhibition of this spinal reflex.


Assuntos
Músculo Liso/inervação , Inibição Neural , Nociceptividade , Nociceptores/metabolismo , Nervo Pudendo/metabolismo , Receptor de Glutamato Metabotrópico 5/metabolismo , Reflexo , Nervos Espinhais/metabolismo , Bexiga Urinária Hiperativa/metabolismo , Bexiga Urinária/inervação , Ácido Acético , Potenciais de Ação , Animais , Gatos , Modelos Animais de Doenças , Antagonistas de Aminoácidos Excitatórios/farmacologia , Feminino , Masculino , Contração Muscular , Fibras Nervosas Amielínicas/efeitos dos fármacos , Fibras Nervosas Amielínicas/metabolismo , Inibição Neural/efeitos dos fármacos , Nociceptividade/efeitos dos fármacos , Nociceptores/efeitos dos fármacos , Nervo Pudendo/efeitos dos fármacos , Nervo Pudendo/fisiopatologia , Piridinas/farmacologia , Receptor de Glutamato Metabotrópico 5/antagonistas & inibidores , Reflexo/efeitos dos fármacos , Transdução de Sinais , Traumatismos da Medula Espinal/metabolismo , Traumatismos da Medula Espinal/fisiopatologia , Nervos Espinhais/efeitos dos fármacos , Nervos Espinhais/fisiopatologia , Tiazóis/farmacologia , Vértebras Torácicas , Fatores de Tempo , Bexiga Urinária Hiperativa/induzido quimicamente , Bexiga Urinária Hiperativa/fisiopatologia , Bexiga Urinária Hiperativa/terapia , Urodinâmica
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