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“A New Algorithm for the Management of

Pudendal Nerve Entrapment:The role of


physical therapy, electrophysiological
testing and surgical decompression”

E.Bautrant(1), S.Prendergast(2), E.deBisschop(1),


V.Vaini-Elies(1), E. Rummer(2), T.Bensousan(1),
C.Pomel(1)

(1)Centre Grand Angle de Rehabilitation Pelvi-Perineal.


Aix en Provence.France
(2)Pelvic Health and Rehabilitation Center,
San Francisco, California
Symptoms of Pudendal Neuralgia
• Pelvic Pain
• Urinary Dysfunction
• Bowel Dysfunction
• Sexual Dysfunction
Pelvic Pain Symptoms
Typically worsened with sitting and improved in
standing
Territories of the terminal branches

Shafik(1999),Bautrant(2003),Schraffordt(2004),Beco(2004)

• Inferior rectal nerve : anal skin area, anus, rectal


pouch, dorsal half of the anal sphincter
• Perineal nerve : Perineal area, vagina, labial area,
ventral half of the anal sphincter, urethra, bladder
neck?
• Dorsal nerve of the clitoris : Clitoris, groin area ,
iliac area?
Urinary Symptoms
• Dysuria
• Hesitancy
• Frequency
• Urgency
• Slow and/or
interrupted stream
Bowel Symptoms
• Constipation
• Difficulty/inability to
evacuate
• Pain before, during, or
after bowel movement
• Impression of foreign
object in rectum
Sexual Dysfunction
• Female: • Male:
– Pain upon initial penetration
– Erectile dysfunction
– Pain with intercourse
– Post-coital genital burning – Post-coital genital
– Inability/decreased orgasm burning
– Pain during/after orgasm – Inability/decreased
– Sexual arousal syndrome orgasm
– Pain during/after
orgasm
Sexual Dysfunction
Diagnosis score
1 major criterion + 2 minor criteria OR 2 majors criteria

• MAJOR CRITERIA • MINOR CRITERIA

• Pain in the territories of the • Neuralgic pain


terminal pudendal branches • Algic or antalgic position
• Positive trigger test • Sympathetic signs
(Tinel sign ) • Aetiologic or Activating factors
• Hyperesthesia,Dysesthesia, »S • No other reasons for pelvi-perineal
exual Arousal Syndroma » pain

• Positive infiltrative test


Mechanisms of Pudendal Nerve Injury

• Tension injuries: chronic constipation, extended


vaginal deliveries, squatting with excessive
weight, sacro-iliac joint dysfunction (SIJD)

• Compression injuries: falls on tailbone, prolonged


sitting, cycling, excessive abdominal exercises,
gymnastics, horseback riding, SIJD
Mechanisms of Pudendal Nerve
Injury
• Surgical trauma: commonly post-hysterectomy
and radical prostatectomy

• Chronic noxious nerve stimulation:


viscerosomatic, endometriosis, recurrent cystitis,
recurrent vaginitis

• Congenital Syndrome ?
Sites of Pudendal Nerve Injury

1. Soft tissue, osseus or


fibro-osseus tunnels

2. Places where the


nervous system
branches
Sites of Pudendal Nerve Injury

3. Places where the system


is relatively fixed

4. Places in close proximity


to unyielding interfaces
SACRAL NERVE ROOT NOXIOUS INPUT PUDENDAL NERVE
COMPRESSION/TRAUMA ENTRAPMENT
•Myofascial Dysfunction
(+) sacral reflex testing
•Visceral-somatic interaction
•Recurrent cystitis and
vaginitis and endometriosis
TREATMENT:
Decompression surgery
and Physical Therapy

Pudendal Neuralgia

TREATMENT:
Non-surgical medical management and Physical Therapy
SACRAL NERVE ROOT NOXIOUS INPUT PUDENDAL NERVE
COMPRESION/TRAUMA ENTRAPMENT
•Myofascial Dysfunction
(+) sacral reflex testing
•Viscerosomatic interaction
•Recurrent cystitis/vaginitis

•endometriosis TREATMENT:
Decompression surgery
and Physical Therapy

PUDENDAL NEURALGIA

TREATMENT:
Non-surgical medical management and Physical Therapy
Conservative Treatment

• Medical Management

• Physical Therapy

• Lifestyle Modifications
Medical Management
• Pudendal Nerve Blocks

• Trigger Point Injections/Dry Needling

• Topical Creams/Lidoderm patches

• Pharmaceutical Management

• Stress reduction techniques


Physical Therapy
• Lengthen Pelvic Floor
• Minimize Subcutaneous Panniculosis
• Eradicate extrapelvic/intrapelvic MTrPs
• Reduce Adverse Neural Tension
• Stabilize/Correct SIJD
• Normalize NM recruitment patterns and
motor control
Lifestyle Modifications:
minimize aggravating factors
• Appropriate cushion (Rodin)

• Exclude symptom-inducing exercises

• Underwear and clothing modifications

• Diet modifications

• Limit/cease menses
SACRAL NERVE ROOT NOXIOUS INPUT PUDENDAL NERVE
COMPRESSION/TRAUMA ENTRAPMENT
•Myofascial Dysfunction
(+) sacral reflex testing
•Viscerosomatic interaction
•Recurrent cystitis/vaginitis

•endometriosis TREATMENT:
Decompression surgery
and Physical Therapy

PUDENDAL NEURALGIA

TREATMENT:
Non-surgical medical management and Physical Therapy
Electro-Physiological tests

Terminal conduction Times(Pnmlt)


Evaluated by endocavitary stimulation:

-Can be modified by the muscle


contraction of the suffering patient

-Are not specific of a compression


Only indicate a nerve demyelinisation

-Their best indication for us :


The intra operative tests
Electro-Physiological tests

· Sacral medular reflex +++


Most valuable for testing the afferent
and efferent conduction of the PN
And the medullary S2-S4 system of
Data processing

-Stimulation : Clitoridian area


-Recording : anal sphincter
Ventral half = PeN / Dorsal half= IRN
- Pubo-rectalis recording = Levator N

The Evoked Potentials : Stimulation


the Pudendal dermatomas
Recording of the sensitive conductions
761 PUDENDAL NEURALGIAS AND 300 DECOMPRESSIONS
OCT 1998 ⇒ MAY 2005

SURGICAL PUDENDAL NERVE DECOMPRESSION


THE TRANS-ISCHIO-RECTAL APPROACH

Centre Grand Angle de Réhabilitation Pelvi-périnéale


AIX-EN-PROVENCE
FRANCE
The sites of entrapment

„Inter ligamental grip : 59%

„Falciform process : 41%

„Both : 38%

„Alcock canal : 8%
Requirements for Pudendal Surgery in 2005

• Reduce the pressure in the Pudendal canal


• Avoid any dissection of the nerve itself
• Make sure of the complete decompression of all the sites
of entrapment
• Use a non invasive procedure to avoid important
musculoskeletal reactions
• If possible control the normalization of the latencies
Trans-ischio-rectal decompression
• Anatomical relation with the 3
segments of the pudendal nerve:
– Initial segment
– Inter ligamental segment
– Alcock tunnel
• Low aggressivity and best route
to reduce the pressure in the
Pudendal canal
• Female (205) : vaginal route
• Male (95) : perineal route
Trans-ischio-rectal decompression :
300 cases
• Median posterior vaginal incision
• Section of recto-vaginal ligament and
entry in the ischio rectal fossea
• Dissection of the internal side of the
pelvis and the sacro -spinous
ligament(SSL)
• Opening of the pudendal tunnel by
section of the inferior edge of SSL
• Decompression of the inter ligamental
grip by progessive rising section of the
SSL under endoscopic control .
• Decompression of the Alcock tunnel
after section of the Falciform process
and conservative mobilisation of the
elevator ani .
• Objective = decompression
INCISION IN MALE
DECOMPRESSION
ISCHIO-RECTAL FOSSEA
IN MALE DISSECTION
TRANS VAGINAL ROUTE
IN FEMALE
ENTRY IN ISCHIO RECTAL FOSSEA
INTRA OPERATIVE ELECTRO-PHYSIOLOGICAL TESTS :
1- LOCALIZATION OF THE ENTRAPMENT
INTRA OPERATIVE ELECTRO-PHYSIOLOGICAL TESTS:
2- CONTROL OF COMPLETE NERVE LIBERATION
3ms/div-
3 ms/div 20uV/div
– 20 µV/div
G Pud e nd al
G Pud e nd al

1
1
3 1
2
3 0ms 20 µV
3
4 20 µV
3 0ms
3 0ms 20 µV
11
5

1
3

Intraoperative endorectovaginal time conduction Intraoperative endorectovaginal time


before decompression: 11,30 ms conduction after decompression: 6,50 ms
Post operative period
• Drainage and discharge at D4
• Less post operative pain (catheter for
antalgic infusion with implanted chamber in
36 cases )
• Urinary infections : 6 cases
• 6 Haemorrhage complications (2%)
• 6 Ischio rectal fossea abscess (2%)
Haemorrhagic complications

• 1 operative lesion : Internal Pudendal artery

• 5 secondary haemorrhages (D1,D4,D5,D8,D10)


= Embolization
- Ischiatic artery (1)
- Inferior gluteal artery (1)
- Branches of Internal Pudendal artery (3)

O 1 transfusion
Outcome : Valuation of the results

• Pain valuation Score (VAS)


• Questionnaire « Dallas » quality of life :
Dysruption rate (%)
. In the daily activities
. at work or in leasure activities
. in emotional behaviour
. in relationship
Outcome : Evaluation of the results

• Visual Analog Scale (VAS)


• Dallas Pain Questionnaire
Dysruption rate (%):
. Activities of Daily Living
. At work or in leasure activities
. Emmotional health
. Effect on relationship
Outcome : Evaluation of the results

• Significant improvement = Painless or


improvement of the Pudendal pain > 50% of the
initial levels ( VAS + « Dallas »)
• Cured : No pudendal pain = complete recovery
• Recording of the results :
- T0 : First 3 months post-op
- T6 : 6 months after surgery
- T12 : 1 year after surgery
- T24 : 2 years after surgery
Outcome : The results
• T0 (3 months) : 177/300 Improvement ( 59%)
153/300 Recoveries (51%)

• T6 (6months) : 204/276 Improvement (74%)


146/276 Recoveries (53%)

• T12 ( 1year ) : 177/221 Improvement (80%)


139/221 Recoveries (63%)

• T24 ( 2years ) : 116/140 Improvement (83%)


89 /140 Recoveries (63%)
Outcome : The results
100
90
80
70
60
Improved
50
Cured
40 Still in pain
30
20
10
0
Pre-op T0 T6 T12 T24
Outcome : The results
• Increasing of pain : 0
• No improvement 1 year : 44 cases/221
• No improvement 2 years : 24 cases/140
• 22% ( 66 cases ) experienced post-op other issues of pain :
- Piriformis syndromes : 21 cases (7%)
- SIJ dysfunction : 0
- Other pains : 12 cases (4%)
- Adenomyosis : 39 cases (13%)
Outcome : Effects on continence, rectal
and sexual dysfunctions
• Urinary incontinence : 39 cases pre-op
-Stress I (29) : Improved 12 / Aggravated 0
-Urge I (17): Improved 10 / Aggravated 0
• Anal incontinence : 18 cases pre-op
-Improved 8 / Aggravated 0
-Post -op 2 cases ( Improved in the 3 months )
• Rectal dyschesia : 22 cases pre-op
-Improved 4 / Aggravated 6
• Sexual dysfunction :
-Pre-op Orgasm dysfunction 31 / Improved 26
-Pre-op Erection dysfunction12 / Improved 10
SACRAL NERVE ROOT NOXIOUS INPUT PUDENDAL NERVE
COMPRESSION/TRAUMA ENTRAPMENT
•Myofascial Dysfunction
(+) sacral reflex testing
•Visceral-somatic interaction
•Recurrent cystitis and
vaginitis and endometriosis
TREATMENT:
Decompression surgery
and Physical Therapy

Pudendal Neuralgia

TREATMENT:
Non-surgical medical management and Physical Therapy
Conclusion
• Management of Pudendal Neuralgia requires a
multi-diciplinary approach:

• Physical Therapy, medical management, and lifestyle


modifications

• If conservative management fails, surgery can give


improvement in up to 80% of patients with PNE

• Post-operative rehabilitation is required to normalize


secondary musculoskeletal dysfunction from nerve
entrapment

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